Comprehensive Healthcare Inspection Program Review of the VA New Jersey Health Care System, East Orange, New Jersey

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the VA New Jersey Health Care System. 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: 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 Facility leaders have worked together as a team since February 28, 2017. The OIG noted that Facility leaders appeared actively engaged with employees and patients. Organizational leaders support efforts related to patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the Facility through active stakeholder engagement). However, the presence of organizational risk factors, as evidenced by sentinel events, disclosures, and Patient Safety Indicator data, may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. Although the leadership team was knowledgeable about selected SAIL metrics, the leaders should take actions to improve care and performance of poorly performing Quality of Care and Efficiency metrics that are likely contributing to the Facility’s drop from its previous “3-Star” rating to the current “2-Star” rating. The OIG noted findings in three of the clinical operations reviewed and issued six recommendations that are attributable to the Director, Chief of Staff, and Associate Director–Lyons Campus. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (2) Environment of Care • Medical equipment storage • Documentation of response time during panic alarm testing (3) Medication Management: Controlled Substances Inspection Program • Correction of Annual Physical Security Survey deficiencies