Report Summary

Title: Comprehensive Healthcare Inspection of the Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
Report Number: 18-04679-239 Download
Issue Date: 9/27/2019
City/State: Richmond, VA
Fredericksburg, VA
Charlottesville, VA
Emporia, VA
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 Hunter Holmes McGuire VA Medical Center, 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 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 had generally stable executive leadership, but the OIG had concerns with long-term Nursing Service leadership vacancies and minimal recruitment efforts. Employee satisfaction and patient experiences in the inpatient and specialty care settings also need improvement. The leadership team should review steps to identify cases that may need institutional disclosures and evaluate the process of identifying improvement opportunities. The leadership team needs to improve their knowledge about selected SAIL and CLC metrics and the actions necessary to sustain and improve performance that contribute to the SAIL “4-star” and CLC “1-star” quality ratings.

The OIG issued 21 recommendations:

(1) Quality, Safety, and Value

• Physician utilization management advisors’ documentation

• Root cause analyses

• Resuscitative episode reviews

(2) Medical Staff Privileging

• Focused and ongoing professional practice evaluation processes

(3) Environment of Care

• General cleanliness and safety

(4) Controlled Substances Inspections

• Controlled substances inventories/checks, documentation, and reconciliation

• Pharmacy inspections and medication destruction

• Verification of prescription pads and written prescriptions

(5) Military Sexual Trauma (MST) Follow-up and Staff Training

• MST training

(6) Antidepressant Use among the Elderly

• Patient/caregiver education and understanding of medications

• Medication reconciliation

(7) Abnormal Cervical Pathology Results Notification and Follow-up

• Full-time women veterans program manager

(8) Emergency Departments and Urgent Care Center Operations

• Licensed mental health provider availability

• Directional signage