Comprehensive Healthcare Inspection of the Dayton VA Medical Center in Ohio

Report Information

Issue Date
Report Number
20-01271-64
VISN
10
State
Indiana
Ohio
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Medical Staff Privileging Credentialing
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
10
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

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 Dayton VA Medical Center and multiple outpatient clinics in Ohio and Indiana. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Privileging; 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 for five weeks at the time of the OIG’s inspection. The team faced multiple challenges, including responding to the COVID-19 pandemic and beginning the electronic health record modernization. Although leaders have opportunities to improve veteran experiences, most survey results for women veterans were generally better than those for female patients nationally. Review of accreditation findings, sentinel events, and disclosures did not identify any substantial risks, although the OIG noted a repeat finding from the previous comprehensive healthcare inspection visit related to completion of all required focused professional practice elements. Leaders were able to speak knowledgeably about selected data used in Strategic Analytics for Improvement and Learning models and actions taken to maintain or improve performance. The OIG issued 10 recommendations for improvement in five areas: (1) Medical Staff Privileging • Professional practice evaluations • Provider exit reviews (2) Medication Management • Committee oversight (3) Mental Health • Follow-up visits • Patient safety plans (4) Care Coordination • Treatment plan referral and review (5) Women’s Health • Collateral duties

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures service chiefs define in advance, communicate, and document expectations for focused professional practice evaluations in provider profiles.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff determines the reasons for noncompliance and makes certain that service chiefs include the minimum specialty-specific criteria for professional practice evaluations of licensed independent practitioners.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff determines the reasons for noncompliance and makes certain that service chiefs complete and document focused professional practice evaluations on all newly hired licensed independent practitioners and evaluation results are reviewed and documented by the Clinical Executive Board.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director determines reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals’ departure from the medical center.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director determines the reasons for noncompliance and makes certain that the Multidisciplinary Pain Management Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that qualified providers conduct four follow-up visits within 30 days of a High Risk for Suicide Patient Record Flag placement.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that clinicians complete patient safety plans within seven days before or after the current High Risk for Suicide Patient Record Flag date.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that life-sustaining treatment plans for patients who lack both decision-making capacity and a surrogate are referred to and reviewed by the assigned multidisciplinary committee.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the medical center’s Women Veterans Program Manager is free of collateral duties.