Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center, Alabama

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Tuscaloosa VA Medical Center, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; and Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up. The facility’s executive leadership team appeared relatively stable; and, upon review of the facility’s accreditation findings, sentinel events, and disclosures, the OIG did not identify any substantial organizational risk. However, the OIG had concerns regarding the root cause analysis process—corrective actions were not implemented or, if implemented, not measured, allowing existing system vulnerabilities that were not eliminated or controlled and exposing veterans to potential and preventable adverse events. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics and should continue to take actions to improve performance contributing to the SAIL “3-star” and CLC “2-star” quality ratings. The OIG issued 14 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary utilization management data review • Root cause analysis processes (2) Medical Staff Privileging • Ongoing professional practice evaluation process (3) Environment of Care • General safety and cleanliness • Mental health unit panic alarm testing response times • Comprehensive emergency management plan annual review (4) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (5) Antidepressant Use among the Elderly • Medication reconciliation (6) Abnormal Cervical Pathology Results Notification and Follow-up • Assignment of a women’s health medical director • Women Veterans Health Committee core membership • Patient notification of abnormal results