Report Summary

Title: Comprehensive Healthcare Inspection of the Edith Nourse Rogers Memorial Veterans’ Hospital in Bedford, Massachusetts
Report Number: 21-00260-232 Download
Issue Date: 9/9/2021
City/State: Bedford, MA
Lynn, MA
Haverhill, MA
Gloucester, MA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

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 Edith Nourse Rogers Memorial Veterans’ Hospital and three outpatient clinics in Massachusetts. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.

The executive leadership team had worked together for approximately eight months at the time of the OIG virtual review. Survey data revealed opportunities for the Chief of Staff to improve employee perceptions of leaders and the workplace, and the Associate Director Nursing and Patient Care Services to improve employee feelings of respect. The OIG’s review of the hospital’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.

The OIG issued seven recommendations for improvement in three areas:

(1) Mental Health

• Suicide prevention training

(2) Care Coordination

• Transfer form completion

• Medical record transmission

• Nurse-to-nurse communication

(3) High-Risk Processes

• Disruptive behavior committee meeting attendance

• Disruptive behavior and threat assessment training