Comprehensive Healthcare Inspection Program Review of the Robley Rex VA Medical Center, Louisville, Kentucky

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Robley Rex 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. The Director and Associate Director positions were covered with interim appointees until the positions were permanently filled in August 2018 and January 2018, respectively. The leaders were generally engaged with employees and patients as evidenced by high satisfaction scores. Organizational leadership 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 results did not identify any substantial organizational risk factors; however, opportunity exists to improve care and positively affect Quality of Care and Efficiency metrics likely contributing to the Facility’s “3-Star” rating. The OIG noted findings in five of the eight clinical areas reviewed and issued nine recommendations attributable to the Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data • Root cause analysis action feedback to reporting employees or departments (2) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (3) Environment of Care • Facility and CBOC cleanliness and maintenance • Inpatient mental health safety • Emergency Operations Plan and annual review of inventory and assets (4) Medication Management: Controlled Substances Inspection Program • Controlled Substances Coordinator’s monthly summary of findings • Annual physical security survey (5) Women’s Health: Mammography Results and Follow-up • Mammogram results electronically linked to radiology order