Comprehensive Healthcare Inspection Program Review of the Beckley VA Medical Center, West Virginia

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of inpatient and outpatient care delivered at the Beckley 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 leadership team appears stable with the hiring of the Chief of Staff and Associate Director in November 2017. The leaders are committed to continuous active engagement with employees and patients. The OIG’s review did not identify any substantial organizational risk factors. However, the OIG noted that the Facility appears to have opportunities to improve the reporting and tracking of sentinel events. The senior leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning metrics and should continue to take actions to improve performance of selected Quality of Care and Efficiency metrics likely contributing to the most current “3-Star” rating. The OIG noted findings in five of the eight areas of clinical operations reviewed and issued eight recommendations that are attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Ongoing Professional Practice Evaluation processes (2) Environment of Care • Frequency, participation, and documentation of Environment of Care rounds (3) Medication Management: Controlled Substances Inspection Program • Correction of annual physical security survey deficiencies • Verification of controlled substances orders (4) Women’s Health: Mammography Results and Follow-Up • Mammography results electronically linked to the radiology order (5) High-Risk Processes: Central Line-Associated Bloodstream Infection • Staff training