Report Summary

Title: Comprehensive Healthcare Inspection Program Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi
Report Number: 18-01142-25 Download
Issue Date: 12/6/2018
City/State: Jackson, MS
Columbus, MS
Greenville, MS
Hattiesburg, MS
Kosciusko, MS
McComb, MS
Meridian, MS
Natchez, MS
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the G.V. (Sonny) Montgomery VA Medical Center. The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Credentialing and Privileging; Environment of Care (EOC); Medication Management: Controlled Substances 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.

Four of five Facility leadership positions were filled by permanent staff for at least a year prior to the OIG’s on-site visit. The Acting Associate Director had been in place since April 2018. The OIG noted opportunities to improve employee and patient satisfaction; and 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 was generally knowledgeable about selected Strategic Analytics for Improvement and Learning metrics, the leaders should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics that are likely contributing to the current “2-Star” rating.

The OIG noted findings in four of the clinical operations reviewed and issued 11 recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are:

(1) QSV

• Protected peer review process

(2) Credentialing and Privileging

• Focused and Ongoing Professional Practice Evaluation processes

(3) EOC

• Storage of medical equipment and supplies

• Mental health seclusion room safety

• CBOC EOC rounds and medication storage and disposal

• CBOC environmental cleanliness and storage requirements

(4) Mental Health: Posttraumatic Stress Disorder Care

• Suicide risk assessments

• Diagnostic evaluations