Report Summary

Title: Comprehensive Healthcare Inspection of Veterans Integrated Service Network 1: VA New England Healthcare System, Bedford, Massachusetts
Report Number: 19-06866-68 Download
Issue Date: 1/29/2020
City/State: Bedford, MA
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 leadership performance and oversight by the Veterans Integrated Service Network (VISN) 1: VA New England Healthcare System, covering leadership and organizational risks and key processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; and Medication Management: Controlled Substances Inspections. The OIG conducted this unannounced visit while concurrent inspections of the following VISN 1 facilities were also performed: VA Central Western Massachusetts Healthcare System, Leeds, MA; Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; and Manchester VA Medical Center, NH.

The VISN 1 leadership team appeared relatively stable. Employee satisfaction scores were generally better than VHA averages. However, opportunities appear to exist for the network director to improve employee satisfaction; the deputy network director to model servant leadership; and the network director, deputy network director, and chief medical officer to reduce employee moral distress at work. Patient experience results were above VHA averages. VISN 1 leaders supported efforts to provide accessible and inclusive care for women veterans, and access metrics and clinician vacancies did not identify any significant organizational risks. Leaders appeared knowledgeable about efforts taken to reduce veteran suicide as well as selected Strategic Analytics for Improvement and Learning and community living center performance metrics; but should continue to support facility actions to improve care provided throughout VISN 1.

The OIG issued 12 recommendations for improvement:

(1) Quality, Safety, and Value

• Acute inpatient stay reviews

• Utilization management data reviews

• Minimum of eight root cause analyses

(2) Medical Staff Privileging

• Focused and ongoing professional practice evaluation processes

(3) Environment of Care

• VISN comprehensive environment of care program

• VISN emergency management committee processes

(4) Medication Management: Controlled Substances Inspections

• Quarterly trend report reviews