Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center in Alabama

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Tuscaloosa VA Medical Center and one outpatient clinic in Alabama. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The executive leaders worked together for four months; however, the Director and the Associate Director for Patient Care Services had worked together since 2015. Survey results revealed opportunities for the Associate Director for Patient Care Services to improve employee satisfaction. Survey data indicated that patients were generally satisfied with their care experiences, but there were opportunities to improve appointment wait times. Review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. However, the OIG identified concerns regarding peer review and patient safety programs. The executive leaders were extremely knowledgeable within their scope of responsibilities about Strategic Analytics for Improvement and Learning data and should continue to act to sustain and improve performance. The OIG issued 14 recommendations for improvement in five areas: (1) Environment of Care • Emergency egress accessible • Wheelchair maintenance (2) Mental Health • Community outreach • Patient follow-up (3) Care Coordination • Goals of care conversations • Multidisciplinary committee representatives and activities (4) Women’s Health • Staffing requirements (5) High-Risk Processes • Equipment inventory file • Instrument tracking system • Annual risk analysis • Environmental cleanliness • Sterile area climate control • Staff training