Comprehensive Healthcare Inspection Program Review of the Dayton VA Medical Center, 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 Dayton VA Medical Center, Ohio (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. Three of four Facility leadership positions were filled by interim or acting staff, with long-term Facility leaders in two positions. Organizational leaders 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 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 current “4-Star” rating. The OIG noted findings in four of eight areas of clinical operations reviewed and issued 10 recommendations attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies were: (1) Quality, Safety, and Value • Completion of inpatient admissions and continued stay reviews • Physician Utilization Management (UM) Advisors’ documentation of decisions • Interdisciplinary review of UM data (2) Credentialing and Privileging • Focused Professional Practice Evaluation processes (3) Environment of Care • Completion of Environment of Care (EOC) rounds • Facility cleanliness and maintenance • Medical equipment safety inspections (4) Long-term Care: Geriatric Evaluations • Program oversight and evaluation • Medical evaluation • Implementation of interdisciplinary plan of care