Comprehensive Healthcare Inspection Program Review of the Alexandria VA Health Care System, Pineville, Louisiana

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Alexandria VA Health Care System (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; Long-Term Care: Community Nursing Home Oversight; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 105 employees. The facility has stable executive leaders who support patient safety, quality care, and other positive outcomes. OIG’s review of accreditation organization findings, sentinel events, disclosures, and Patient Safety Indicator data did not identify any substantial organizational risk factors. The executive leaders appear to have active engagement with employees but need to continue efforts to improve patient experience scores. The leaders also seemed knowledgeable about selected Strategic Analytics for Improvement and Leaning (SAIL) metrics but should make significant efforts to improve care and performance, particularly Quality of Care and Efficiency metrics likely contributing to the current 2-star SAIL rating. OIG noted findings in five of the six areas of clinical operations reviewed and issued nine recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Review of Ongoing Professional Practice Evaluation data (2) Medication Management: Anticoagulation Therapy • Patient education specific for newly prescribed anticoagulant medications (3) Environment of Care • Participation on environment of care rounds • Safe and clean environment in all patient care areas • Locked mental health unit employee and Interdisciplinary Safety Inspection Team training (4) Long-Term Care: Community Nursing Home Oversight • Community Nursing Home Oversight Committee representation • Cyclical clinical visits (5) Post-Traumatic Stress Disorder Care • Suicide risk assessments • Referral for diagnostic evaluations