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 Providence VA Medical Center (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home (CNH) Oversight. The OIG also provided crime awareness briefings to 24 employees. The facility has generally stable executive leadership and active engagement with patients as evidenced by high satisfaction scores. Organizational leaders support 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). The OIG’s review of accreditation organization findings, sentinel events, disclosures, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors. The OIG noted findings in four of the six areas of clinical operations reviewed and issued 12 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) QSV • Review of Ongoing Professional Practice Evaluation data • Completion of individual root cause analyses • Annual patient safety report submission (2) Coordination of Care: Inter-Facility Transfers • Transfer data collection and analysis • Staff/attending physician involvement and countersignature on transfer notes written by acceptable designees • Provision of medical care prior to transfer (3) EOC • Emergency equipment inspection • Documentation of VA Police response time to panic alarm system testing for locked mental health units • Mental health Interdisciplinary Safety Inspection Team training (4) Long-Term Care: CNH Oversight • Oversight committee meeting frequency, membership representation, and program integration • Completion of annual reviews • Cyclical clinical visits
| Report Date | Agency Reviewed / Investigated | Report Title | Type | Location | |
|---|---|---|---|---|---|
| Department of Veterans Affairs | Comprehensive Healthcare Inspection Program Review of the Providence VA Medical Center, Providence, Rhode Island | Review |
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| Department of Defense | Summary Report on U.S. Direct Funding Provided to Afghanistan | Audit | Agency-Wide | View Report | |
| Department of Health & Human Services | New Jersey Claimed Federal Medicaid Reimbursement for Children's Partial Hospitalization Services That Did Not Meet Federal and State Requirements | Audit |
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View Report | |
| Appalachian Regional Commission | Performance Measures | Review | Agency-Wide | View Report | |
| Appalachian Regional Commission | Broadband Expansion in Campbell County | Inspection / Evaluation |
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| Appalachian Regional Commission | Applications and Approvals | Review | Agency-Wide | View Report | |
| Department of Commerce | Strengthening Grant Processes Will Improve the Management of the Band 14 Incumbent Spectrum Relocation Grant Program | Audit | Agency-Wide | View Report | |
| Social Security Administration | Using Nursing Home Data to Determine Suitability of Representative Payees | Audit | Agency-Wide | View Report | |
| Social Security Administration | Progress in Developing the Disability Case Processing System as of February 2018 (Congressional Response Report) | Audit | Agency-Wide | View Report | |
| Internal Revenue Service | Affordable Care Act: Processes to Identify Employers Subject to the Employer Shared Responsibility Payment Need Improvement | Audit | Agency-Wide | View Report | |