Report Summary

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Corporal Michael J. Crescenz 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 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 had worked together for one month, except for the assistant director who was on detail prior to and through the OIG’s on-site visit. The OIG found the facility average for several selected survey leadership questions were generally similar or better than the VHA average. One of four patient survey results reflected better care ratings than the VHA average. 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 generally knowledgeable within their scope of responsibility, and time in their positions, about selected SAIL and CLC metrics but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “3-star” and CLC “2-star” quality ratings.

The OIG issued six recommendations for improvement in the following areas:

(1) Medical Staff Privileging

• Focused professional practice evaluation process

(2) Medication Management: Controlled Substances Inspections

• Inventory balance adjustment processes

(3) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training

• MST training

(4) Geriatric Care: Antidepressant Use among the Elderly

• Patient/caregiver education and understanding of medications

(5) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up

• Women Veterans Health Committee processes

• Patient notification of abnormal results