Comprehensive Healthcare Inspection Program Review of the Memphis VA Medical Center

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Memphis VA Medical Center (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 183 employees. The Facility appears to have stable executive leadership that needs to improve patient satisfaction. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results identified recent delivery of poor care and substantial future organizational risks if improvements are not made. The senior leaders should take actions to improve care and performance of SAIL metrics (Quality of Care and Efficiency) likely contributing to the current “1-Star” rating. The OIG noted findings in six areas reviewed and issued 13 recommendations attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Documentation of patient safety incidents in WebSPOT database (2) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (3) Environment of Care • Attendance of environment of care rounds • Safety and cleanliness of patient care areas • Contamination prevention in equipment storage areas • CBOC medication safety and means of egress • Cleanliness of food service and storage areas (4) Medication Management: Controlled Substances Inspection Program • Completion of annual Controlled Substances Inspector training (5) Long-Term Care: Geriatric Evaluations • Program evaluation and performance improvement (6) High-Risk Processes: Central Line-Associated Bloodstream Infections • Staff training