Comprehensive Healthcare Inspection of the VA Connecticut Healthcare System, West Haven, Connecticut

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the VA Connecticut Healthcare System, 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; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. At the time of the OIG site visit, the executive team, except for the acting chief of staff, had been working together for over two years. The facility average for selected survey leadership questions was generally similar to the VHA average. All four patient survey results reflected better care ratings than the VHA average. The OIG’s review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. The leadership team should continue to take actions to sustain and improve performance of measures contributing to the Strategic Analytics for Improvement and Learning “5-star” and community living center “1-star” quality ratings. The OIG issued 13 recommendations for improvement: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (2) Controlled Substances Inspections • Appointment limits of controlled substances inspectors • Rotation of controlled substance areas for inspection • Reconciliation of controlled substances dispensed from and returned to pharmacy • Routine inspections by controlled substances coordinator • Review of override reports (3) Military Sexual Trauma Follow-up and Staff Training • Primary care and mental health providers’ training (4) Antidepressant Use among the Elderly • Patient/caregiver education and understanding of medications • Medication reconciliation (5) Abnormal Cervical Pathology Results and Follow-Up • Patient notification of abnormal results