Comprehensive Healthcare Inspection Program Review of the Central Alabama Veterans Health Care System, Montgomery, Alabama

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 Central Alabama Veterans 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; Environment of Care; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Mental Health Residential Rehabilitation Treatment Program; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 194 employees. The facility has generally stable executive leadership and ongoing processes to improve employee and patient satisfaction. 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 about selected 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 3-star rating. OIG noted findings in four of the six areas of clinical operations reviewed and issued seven recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Ongoing Professional Practice Evaluation data review (2) Coordination of Care: Inter-Facility Transfers • Informed consent and required transfer documentation (3) Environment of Care • Attendance of Environment of Care rounds • Locked mental health unit Interdisciplinary Safety Inspection Team training (4) Post-Traumatic Stress Disorder Care • Completion of suicide risk assessments • Referral for and completion of diagnostic evaluations