Comprehensive Healthcare Inspection Program Review of the Northport VA Medical Center, New York

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Northport VA Medical Center (Facility). The review covered key 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: Post-Traumatic 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. The current Director and the Associate Director were permanently assigned in June 2017. The former Chief of Staff and Associate Director for Patient Care Services were assigned to positions outside the Facility in August 2017, and the positions have since been filled by interim appointees. Further, opportunities appear to exist for the Director and Associate Director to provide a workplace environment where employees feel safe to bring forth issues or ethical concerns. The lack of consistent leadership oversight of quality improvement activities may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and monitored. The OIG noted findings in five of the clinical operations reviewed and issued 11 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) QSV • Interdisciplinary utilization management data reviews • Implementation of root cause analysis actions and provision of feedback • Facility Leaders’ review of annual patient safety report (2) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (3) EOC • EOC rounds frequency • Pest management program • Safe and clean environment • Medical equipment safety inspection process • Mental Health seclusion room safety (4) Medication Management: CS Inspection Program • Electronic access for performing and monitoring CS balance adjustments (5) Long-Term Care: Geriatric Evaluations • Performance improvement oversight