Comprehensive Healthcare Inspection Program Review of the VA Maine Healthcare System, Augusta, Maine

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 VA Maine Healthcare System. 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 (CS) Inspection Program; Mental Health: 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 had generally stable executive leadership and active engagement with employees and patients to maintain high satisfaction scores. Organizational leadership supported patient safety, quality care, and other positive outcomes, but the presence of organizational risk factors, as evidenced by sentinel events, disclosures, and Patient Safety Indicator data may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. Although the leadership team appeared knowledgeable about selected Strategic Analytics for Improvement and Learning metrics, the leaders should continue to take actions to improve care and sustain performance of selected Quality of Care and Efficiency metrics that are likely contributing to the improvement from the previous “3-Star” rating to the current “5-Star” rating. The OIG noted findings in five of the 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 • Root cause analysis action feedback (2) Credentialing and Privileging • Privileging process • Focused and Ongoing Professional Practice Evaluation processes (3) Environment of Care • Safety data sheet accessibility (4) Medication Management: CS Inspection Program • Monthly CS inspections (5) Long-term Care: Geriatric Evaluations • Program oversight and evaluation