Comprehensive Healthcare Inspection Program Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, Pennsylvania

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 Wilkes-Barre 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 205 employees. The facility has stable executive leadership, specifically with the assignment of a permanent Facility Director. 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. However, OIG noted opportunities to improve both employee satisfaction and patient experiences. The senior leadership team seemed knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance, particularly Quality of Care and Efficiency metrics likely contributing to the current 3-star SAIL rating. OIG noted findings in two of the six areas of clinical operations reviewed and issued three recommendations that are attributable to Chief of Staff, Nurse Executive, and Associate Director. The identified areas with deficiencies are: (1) Environment of Care • Participation on environment of care rounds • Respiratory environment in the Community Living Center units (2) Long-Term Care: Community Nursing Home Oversight • Cyclical clinical visits