Report Summary

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care at the Manchester 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 leadership team is generally stable and has active engagement with employees and patients as evidenced by high satisfaction scores. Leaders supported efforts related to safety and quality care; however, the OIG identified a substantial organizational risk—the lack of available support services. Specifically, the OIG is concerned with the urgent care clinic’s lack of access to on-site support services during evenings, nights, weekends, and holidays and limited availability of staff to provide consistent and immediate advanced airway support for cardiopulmonary resuscitation events. The leaders were knowledgeable about Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to improve care and performance of quality of care metrics contributing to current SAIL ratings.

The OIG issued 17 recommendations for improvement:

(1) Quality, Safety, and Value

• Review of literature for root cause analyses

(2) Medical Staff Privileging

• Focused and ongoing professional practice evaluation processes

(3) Environment of Care

• Maintenance of a clean and safe environment

(4) Mental Health

• Military sexual trauma referrals, training, and communication of initiatives

(5) Geriatric Care

• Justification for medication and reconciliation

• Caregiver/patient medication education

(6) Women’s Health

• Communication of abnormal results to patients

(7) Emergency Departments and Urgent Care Center Operations

• Urgent Care Center registered nurse staffing

• Backup call schedule for Urgent Care Center providers

• Availability of support services