Comprehensive Healthcare Inspection Program Review of the VA Boston Healthcare System, Massachusetts

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the VA Boston Healthcare System (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances 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. The OIG noted that Facility leaders have been in their respective positions for at least four years. Facility leaders were actively engaged with employees and patients and were continuously striving to maintain employee and patient satisfaction scores. Facility leaders appeared to support efforts related to patient safety, quality care, and other positive outcomes. However, the presence of organizational risk factors, as evidenced by Patient Safety Indicator data, may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and monitored. Although the leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics, the leaders should continue to take actions to sustain performance and to improve care and performance of poorly performing Quality of Care and Efficiency metrics that are likely contributing to the current “4-Star” rating. The OIG noted findings in four of the clinical operations reviewed and issued seven recommendations that are attributable to the Director, Chief of Staff, and Deputy Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Evaluation of peer review findings (2) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (3) Environment of Care • Separate storage for clean and dirty equipment • Solid bottom shelving in equipment storage areas (4) Medication Management: Controlled Substances Inspection Program • Annual physical security actions