The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered by the Hampton VA Medical Center (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; Long-Term Care: Community Nursing Home (CNH) Oversight; and Mental Health (MH) Residential Rehabilitation Treatment Program (RRTP). The OIG provided crime awareness briefings to 197 employees. The Facility had a newer executive leadership team that seemed stable, actively engaged with employees, and appeared to support patient safety and quality care. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors. The OIG noted findings in all seven areas of clinical operations reviewed and issued 19 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) QSV • Peer Review Committee actions • Ongoing Professional Practice Evaluation data review (2) Medication Management: Anticoagulation Therapy • Laboratory testing prior to initiating anticoagulation treatment • Employee competency assessments (3) Coordination of Care: Inter-Facility Transfers • Identification of receiving provider (4) EOC • EOC rounds frequency and attendance • Panic alarm testing and police response times • Clean supply storage • Locked MH unit security surveillance system functionality • MH employee and Interdisciplinary Safety Inspection Team training (5) High-Risk Processes: Moderate Sedation • Assessment of patients’ previous adverse experiences with sedation • Physician training prior to reprivileging (6) Long-Term Care: CNH Oversight • CNH Oversight Committee meeting frequency and representation • Integration into the facility quality improvement program • Annual reviews • Social worker and nurse clinical visits (7) MH RRTP • Daily resident room inspections • Security surveillance system functionality
Hampton, VA
United States
