The VA Office of Inspector General (OIG) conducted a follow-up healthcare inspection at the Tuscaloosa VA Medical Center (facility) in Alabama to evaluate the status of patient safety program deficiencies identified in a 2023 OIG report and Veterans Integrated Service Network (VISN) 7’s oversight of the facility’s patient safety program. Additionally, the inspection evaluated actions taken to address deficiencies in the community living center (CLC) regarding residents at risk for elopement identified in a 2022 OIG report.
In contrast to previous findings, the OIG found that the facility’s patient safety program complied with VA-mandated standards. The OIG’s analysis of facility patient safety data showed the patient safety manager appropriately accepted or rejected event reports; considered significant safety events for root cause analysis; and completed eight annually required patient safety analyses for fiscal year 2023.
While the VISN patient safety officer’s oversight of patient safety programs improved, the OIG identified the need for qualitative analysis of patient safety data, which is essential to assess the impact and effectiveness of VISN patient safety programs and develop effective actions plans.
Facility leaders addressed the deficiencies identified in the 2023 and 2022 OIG reports and determined actions taken by the facility leaders resulted in a facility culture where patient safety has become paramount. The OIG concluded that a commitment to continue to administer a high-quality patient safety program was evident in facility leaders’ actions.
The OIG determined that the facility resolved previous concerns regarding the safety and security of the residents in the CLC as well as implemented a review process to ensure electronic health record documentation for residents at risk for elopement was consistent with facility policy.
The OIG made three recommendations to the VISN Director related to the patient safety officer’s qualitative reviews of patient safety data.
Open Recommendations
| Recommendation Number | Significant Recommendation | Recommended Questioned Costs | Recommended Funds for Better Use | Additional Details | |
|---|---|---|---|---|---|
| 01 | Yes | $0 | $0 | ||
| The Veterans Integrated Service Network Director confirms that the patient safety officer reviews investigations by subject matter experts for Joint Patient Safety Reporting events. | |||||
| 02 | Yes | $0 | $0 | ||
| The Veterans Integrated Service Network Director provides evidence to demonstrate the Patient Safety Office is completing reviews of a sample of patient safety events that includes analysis of content, recommendations, and required actions, as outlined in Veterans Health Administration Directive 1050.01. | |||||
| 03 | Yes | $0 | $0 | ||
| The Veterans Integrated Service Network Director ensures that the Veterans Integrated Service Network 7 Quality and Patient Safety Committee minutes reflect that the patient safety officer conducted analysis of patient safety data to identify opportunities for | |||||
