Comprehensive Healthcare Inspection Program Review of the Charles George VA Medical Center, Asheville, North Carolina

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Charles George 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: Posttraumatic 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 leaders had worked together for approximately four months prior to the OIG’s site visit. Organizational leaders appeared to support efforts related to patient safety, quality care, and other positive outcomes as seen with the achievement of the Pathway to Excellence designation. However, organizational risk factors, such as lack of identifying, tracking, and reporting of sentinel events and higher rates of Patient Safety Indicator data may contribute to future issues of noncompliance and/or lapses in patient safety. Although the leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics, the leaders should continue to take actions to improve care and maintain performance of Quality of Care and Efficiency metrics that are likely contributing to the current “5-Star” rating. The OIG noted findings in three of the clinical operations reviewed and issued eight recommendations that are attributable to the Director, and Chief of Staff. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data • Provision of feedback regarding actions taken (2) Credentialing and Privileging • Medical Staff Executive Council’s documentation of privileging process • Focused and Ongoing Professional Practice Evaluation processes (3) Women’s Health: Mammography Results and Follow-Up • Electronic linking of mammogram results to the radiology order • Communication of results to providers and patients