Comprehensive Healthcare Inspection Program Review of the Louis A. Johnson VA Medical Center, Clarksburg, West Virginia

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care at the Louis A. Johnson 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); Credentialing and Privileging; Environment of Care (EOC); Medication Management: Controlled Substances (CS) Inspection Program; Mental Health Care: Posttraumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. At the time of the OIG site visit, the leadership team had been working together for nine months. Facility leaders were generally engaged with patients; working to improve employee satisfaction scores; and appeared to support efforts related to patient safety, quality care, and other positive outcomes. However, the presence of organizational risk factors—lack of identification, tracking, and reporting of sentinel events and disclosure of adverse events—may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and monitored. The leadership team should continue to take actions to improve care and maintain performance of selected Strategic Analytics for Improvement and Learning (SAIL) Quality of Care and Efficiency metrics likely contributing to the current “4-Star” rating. The OIG noted findings in five of the clinical operations reviewed and issued nine recommendations that are attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are: (1) QSV • Physician Utilization Management Advisors’ documentation of decisions • Interdisciplinary review of utilization management data (2) Credentialing and Privileging • Ongoing Professional Practice Evaluation processes (3) EOC • General safety • Emergency power testing and availability (4) Medication Management: CS Inspection Program • CS reconciliation • Verification of Orders (5) High-Risk Processes: Central Line-Associated Bloodstream Infections • Staff education