Comprehensive Healthcare Inspection Program Review of the Huntington VA Medical Center, Huntington, West Virginia

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 Huntington 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; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. OIG also provided crime awareness briefings to 108 employees. The facility’s current leaders have active engagement with employees and patients and are maintaining 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). OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. The senior leadership team was knowledgeable of SAIL metrics but should continue to take actions to improve care and performance of selected SAIL metrics, particularly Quality of Care and Efficiency metrics likely contributing to the current 4-star rating. OIG noted findings in four of the clinical operations reviewed and issued seven recommendations that are attributable to the Facility Director, Chief of Staff, Nurse Executive, and Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value (QSV) • QSV Council meeting minutes (2) Coordination of Care: Inter-Facility Transfers • Nurse documentation of transfer assessments/notes • Communication with the accepting facility (3) Environment of Care (EOC) • EOC rounds attendance • Restriction of access to sterile supplies at the representative community based outpatient clinic (CBOC) • Security of biohazardous waste at the representative CBOC (4) Long-Term Care: Community Nursing Home Oversight • Oversight committee representation