Report Summary

Title: Comprehensive Healthcare Inspection of the Ralph H. Johnson VA Medical Center in Charleston, South Carolina
Report Number: 20-00132-04 Download
Report
Issue Date: 11/5/2020
City/State: Charleston, SC
Savannah, GA
Myrtle Beach, SC
Beaufort, SC
Goose Creek, SC
North Charleston, SC
Hinesville, GA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted
Summary:

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Ralph H. Johnson Medical Center and multiple outpatient clinics in Georgia and South Carolina. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment.

The executive leadership team had worked together in their current positions for five months prior to the inspection, although three of the five leaders had worked together for several years. Survey scores related to employee satisfaction were generally better than those for VHA. Patient experience survey data indicated satisfaction with the care provided. Leaders appeared to support efforts to improve and maintain patient safety, quality care, and other positive outcomes. The OIG’s review of accreditation findings and disclosures did not identify any substantial organizational risk factors. The leaders were knowledgeable about Strategic Analytics for Improvement and Learning data and should continue to take actions to sustain and improve performance.

The OIG issued 13 recommendations for improvement across six areas:

(1) Quality, Safety, and Value

• Peer review processes

(2) Medical Staff Privileging

• Professional practice evaluations

• Provider exit reviews

(3) Environment of Care

• Safety and cleanliness

(4) Mental Health

• Staff training

(5) Women’s Health

• Women’s health primary care providers

• Committee membership

• Maternity care coordinator

(6) High-Risk Processes

• Airflow testing