Comprehensive Healthcare Inspection Program Review of the VA Pittsburgh Healthcare System, Pennsylvania

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 VA Pittsburgh Healthcare 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, permanently appointed staff who have been working as a team since January 2016, supported patient safety, quality care, and other positive outcomes. However, the presence of organizational risk factors, as evidenced by Patient Safety Indicator data and root cause analyses, may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. The leadership team was knowledgeable about selected SAIL metrics and should continue to take actions to maintain and improve care and performance of selected Quality of Care and Efficiency metrics that are likely contributing to the current “4-Star” rating. The OIG noted findings in two of the eight clinical areas reviewed and issued four recommendations that are attributable to the Deputy Director and Chief of Staff. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (2) Environment of Care • Facility and CBOC environmental cleanliness and maintenance • Inpatient mental health safety