Comprehensive Healthcare Inspection Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Samuel S. Stratton VA Medical Center (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Credentialing and Privileging; Quality, Safety, and Value (QSV); Environment of Care (EOC); Medication Management: Controlled Substances (CS) Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The OIG also provided crime awareness briefings to 64 employees. Facility leaders were actively engaged with employees and patients and were working to improve employee satisfaction scores (such as initiating processes and plans to maintain positive perceptions of the facility). Organizational leadership appears to support patient safety and quality care. However, the OIG is concerned with the number of sentinel events, institutional disclosures, and post-operative/post-procedural adverse events. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics likely contributing to the 3-star rating. The OIG noted findings in five areas of clinical operations reviewed and issued 10 recommendations that are attributable to the Interim Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Use of Ongoing Professional Practice Evaluation results for reprivileging (2) QSV • Documentation of decisions by physician utilization management (UM) advisors • Interdisciplinary group review of UM data • Feedback about root cause analysis actions (3) EOC • Frequency and attendance of EOC rounds • Security of medical biohazardous waste storage areas (4) Medication Management: CS Inspection Program • CS order verification • Inventories of pharmacy prescription pads (5) Women’s Health: Mammography Results and Follow-Up • Communication of results to patients