The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Miami VA Healthcare System (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. OIG also provided crime awareness briefings to 79 employees. The facility has stable executive leadership and active engagement with employees and patients. Organizational leaders supported patient safety, quality care, and other positive outcomes by enacting processes and plans to maintain positive perceptions of the facility through active stakeholder engagement. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Senior leaders were knowledgeable about selected SAIL metrics and continue to take actions to improve care and performance. OIG noted findings in six of the clinical operations reviewed and issued 11 recommendations that are attributable to the Facility Director, Chief of Staff, Associate Director, and Assistant Director. The identified areas with deficiencies are: (1) QSV • Review of credentialing and privileging data every 6 months • Physician utilization management advisor’s documentation of decisions (2) Coordination of Care: Inter-Facility Transfers • Transfer data collection and reporting (3) EOC • EOC rounds attendance and frequency • Locked MH unit panic alarm testing (4) High-Risk Processes: Moderate Sedation • Informed consent notification of provider changes and documentation (5) Long-Term Care: CNH Oversight • CNH Oversight Committee requirements • Annual reviews of CNHs • Cyclical clinical visits (6) MH Residential Rehabilitation Treatment Program • Daily room inspections for unsecured medications
Miami, FL
United States
