Report Summary

Title: Comprehensive Healthcare Inspection of the Charlie Norwood VA Medical Center, Augusta, Georgia
Report Number: 19-00013-15 Download
Issue Date: 11/21/2019
City/State: Augusta, GA
Athens, GA
Statesboro, GA
Statesboro, GA
Aiken, SC
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the Charlie Norwood VA Medical Center, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas 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 leaders had been working together since December 2018, have opportunities to improve employee satisfaction and patient experiences, and supported efforts related to safety and quality care. However, the OIG had concerns regarding surgical procedure sentinel events and the lack of a process to capture, track, and trend patient safety indicator data. The leaders were aware of Strategic Analytics for Improvement and Learning (SAIL) metrics but should take actions to improve performance contributing to the facility’s SAIL “2-star” quality ratings.

The OIG issued 24 recommendations for improvement:

(1) Quality, Safety, and Value

• Timely completion, improvement action implementation, and quarterly review of peer reviews

• Interdisciplinary utilization management data reviews

(2) Medical Staff Privileging

• Focused and ongoing professional practice evaluation processes

(3) Environment of Care

• General safety and cleanliness

• Inventory of assets and resources

• Review of comprehensive emergency operations plan

(4) Medication Management

• Leadership oversight of controlled substances summary of findings and trends

• Inspectors’ annual competency assessments

• Monthly physical inventories

• Reconciliation of dispensing and return of stock

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

(5) Mental Health

• Military sexual trauma training

(6) Women’s Health

• Women Veterans Health Committee membership and meetings

• Cervical cancer screening data tracking/follow-up

• Patient notification of abnormal results

(7) Emergency Departments and Urgent Care Center Operations

• Backup call schedule