Report Summary

Title: Comprehensive Healthcare Inspection of the VA Maryland Health Care System, Baltimore, Maryland
Report Number: 19-00016-61 Download
Issue Date: 1/9/2020
City/State: Baltimore, MD
Glen Burnie, MD
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 delivered at the VA Maryland Health Care System, Baltimore, Maryland, covering leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. For this inspection, the 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.

Executive leadership appeared relatively stable. Employee satisfaction scores were generally better than VHA averages; however, patient experience results identified improvement opportunities. Leaders appeared to support efforts to improve and maintain patient safety, quality care, and positive outcomes. Review of accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. Leaders were knowledgeable of Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to act to improve performance measures contributing to the current SAIL ratings.

The OIG issued 23 commendations for improvement:

(1) Quality, Safety, and Value

• Peer review processes

• Interdisciplinary review of utilization management data

• Root cause analysis processes

• Compliance with life-sustaining treatment orders

• Review of resuscitative episodes

(2) Medical Staff Privileging

• Focused and ongoing professional practice evaluation processes

• Reprivileging processes

(3) Environment of Care

• Environmental cleanliness

• Furniture and equipment condition

• Infection prevention and control

• Panic alarm installation and testing

(4) Medication Management: Controlled Substances Inspections

• Monthly controlled substances inspections

• Emergency drug cache inspections

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

• Military sexual trauma training

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

• Women Veterans Health Committee core membership

• Tracking and monitoring cervical cancer data