Report Summary

Title: Comprehensive Healthcare Inspection of the North Florida/South Georgia Veterans Health System, Gainesville, Florida
Report Number: 19-00010-237 Download
Issue Date: 9/27/2019
City/State: Gainesville, FL
Valdosta, GA
Ocala, FL
Saint Augustine, FL
Saint Augustine, FL
Lecanto, FL
Jacksonville, FL
Tallahassee, FL
Marianna, FL
The Villages, FL
Palatka, FL
Waycross, GA
Waycross, GA
Perry, FL
St. Marys, GA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care at the North Florida/South Georgia Veterans Health System, covering leadership, organizational risks, and key processes associated with promoting quality care. Areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Care; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results; and High-Risk Processes: Emergency Department/Urgent Care Center Operations.

The facility’s leadership appeared stable, with four of six positions permanently filled for over one year. Employee satisfaction and patient experience survey were similar to or higher than VHA averages. Leaders supported efforts related to safety and quality care; however, patient safety indicator data, along with missing institutional disclosure information and conflicting survey report information, may contribute to organizational risks. The leaders were knowledgeable about SAIL metrics but should continue to improve care and performance of quality of care metrics contributing to current SAIL ratings.

The OIG issued 28 recommendations for improvement:

(1) Quality, Safety, and Value

• Interdisciplinary review of utilization management data

• Root cause analyses

• Resuscitative episode reviews

(2) Medical Staff Privileging

• Focused and ongoing professional practice evaluation processes

(3) Environment of Care

• General cleanliness, maintenance, and biohazardous waste storage

• Generator testing

(4) Medication Management

• Monthly inspections and rotation of inspectors

• Verification of orders, drugs held for destruction, prescription pads, hard copy prescriptions, and 72-hour inventories

(5) Mental Health

• Military Sexual Trauma training

(6) Geriatric Care

• Patient/caregiver education

• Medication reconciliation

(7) Women’s Health

• Women Veterans Health Committee membership and reporting

• Cervical cancer screening data tracking

(8) Emergency Departments/Urgent Care Center Operations

• On-call social work support

• Directional signage

(9) Incidental Findings

• Medical record scanning backlog

• Post Anesthesia Care Unit cardiac monitor inspections and oxygen storage