Report Summary

Title: Comprehensive Healthcare Inspection Program Review of the William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina
Report Number: 18-00412-173 Download
Issue Date: 5/17/2018
City/State: Greenville, SC
Florence, SC
Rock Hill, SC
Anderson, SC
Orangeburg, SC
Sumter, SC
Spartanburg, SC
Columbia, SC
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

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 William Jennings Bryan Dorn VA Medical Center (the Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances 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 Facility has stable executive leadership and active engagement with employees as evidenced by 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). The OIG’s review of accreditation organization findings, sentinel events, 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 actively engaged and 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 “2-Star” rating.

The OIG noted findings in four of the eight areas of clinical operations reviewed and issued eight recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are:

1) Credentialing and Privileging

• Focused and Ongoing Professional Practice Evaluation processes

2) Environment of Care

• Core members’ participation in environment of care rounds

• Environmental cleanliness

• Medical equipment safety

3) Mental Health Care

• Timely completion of suicide risk assessments

4) Long-Term Care

• Geriatric evaluation program performance improvement and oversight

• Identification and implementation of geriatric plan of care interventions