Comprehensive Healthcare Inspection Program Review of the West Palm Beach VA Medical Center, Florida

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 West Palm Beach VA Medical Center. 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. Facility leaders appeared actively engaged with employees and patients. Organizational leaders supported 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 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 continue to take actions to improve care and maintain performance of the Quality of Care and Efficiency metrics likely contributing to the improvement from the previous “2-Star” to the current “3-Star” rating. The OIG noted findings in three of the clinical operations reviewed and issued eight recommendations that are attributable to the Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Protected Peer Review process • Physician Utilization Management Advisors’ documentation of decisions • Implementation of root cause analysis actions and provision of feedback (2) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (3) Environment of Care • Staff education of Safety Data Sheets • Environmental cleanliness • CBOC panic alarm testing