Comprehensive Healthcare Inspection Program Review of the Cincinnati VA Medical Center, Cincinnati, Ohio

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 Cincinnati 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 OIG also provided crime awareness briefings to 111 employees. The Facility has generally stable executive leaders who were actively engaged with employees and patients and supported patient safety and quality care. The 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 Quality of Care and Efficiency metrics likely contributing to the “4-Star” ranking. The OIG noted findings in four of the eight areas of clinical operations reviewed and issued seven recommendations that are attributable to the Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: 1) Quality, Safety, and Value • Documentation of patient safety events into the Patient Safety Information System 2) Credentialing and Privileging • Focused Professional Practice Evaluation and Ongoing Professional Practice Evaluation processes 3) Environment of Care • Attendance on environment of care rounds • Contamination prevention in equipment storage shelves 4) Medication Management: Controlled Substances Inspection Program • Controlled substances coordinator (CSC) duties included in Alternate CSC position description • Same-day completion of physical inventories of the controlled substances storage areas