Report Summary

Title: Comprehensive Healthcare Inspection Program Review of the Durham VA Medical Center, North Carolina
Report Number: 18-01146-35 Download
Issue Date: 12/19/2018
City/State: Durham, NC
Greenville, NC
Morehead City, NC
Raleigh, NC
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 in the inpatient and outpatient settings of the Durham VA Medical Center. 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: 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.

Facility leaders were actively engaged with employees and patients and were working to improve employee satisfaction scores by utilizing additional patient survey data and Town Hall meetings. Organizational leaders appeared to support efforts related to patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the Facility through active stakeholder engagement). However, the presence of organizational risk factors, as evidenced by a lack of identification and reporting of sentinel events and institutional disclosures, 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 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 “3-Star” rating.

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

(1) Credentialing and Privileging

• Focused Professional Practice Evaluation process

(2) Medication Management: Controlled Substances Inspection Program

• Pharmacy prescription pad accountability