Comprehensive Healthcare Inspection of the James H. Quillen VA Medical Center, Mountain Home, Tennessee

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the James H. Quillen VA Medical Center. The inspection covers leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. At the time of the review, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility’s executive leadership team appeared stable, with three of the four positions permanently filled for over one year prior to the OIG’s on-site visit. Selected survey scores related to employees’ satisfaction and trust in the facility’s executive leaders were better than VHA averages. Patient experience survey data revealed that scores related to satisfaction with the facility were above VHA averages. The OIG’s review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. The leadership team was knowledgeable within their scope of responsibility about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “4-star” and CLC “2-star” quality ratings. The OIG issued five recommendations for improvement in the following areas: (1) Medication Management: Controlled Substances Inspections • Completion of inspections on day initiated • Reconciliation of dispensing and return of stock for one random day • Emergency drug cache inspections (2) Geriatric Care: Antidepressant Use among the Elderly • Patient/caregiver education on medications