Federal Reports

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