Report Summary

Title: Comprehensive Healthcare Inspection of the VA Central Western Massachusetts Healthcare System in Leeds
Report Number: 21-00263-246 Download
Issue Date: 9/14/2021
City/State: Leeds, MA
Springfield, MA
Pittsfield, MA
Greenfield, MA
Worcester, MA
Fitchburg, 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 VA Central Western Massachusetts Healthcare System in Leeds, which includes multiple 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; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.

The executive leadership team had worked together for seven months at the time of the OIG virtual review. Survey data revealed opportunities for the Director to reduce employee feelings of moral distress and improve workgroup respect and sharing of concerns. The healthcare system’s patient experience scores were generally higher than VHA averages, except for female patients’ access to timely outpatient appointments. 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 five recommendations for improvement in two areas:

(1) Care Coordination

• Patient transfer monitoring and evaluation

(2) High-Risk Processes

• Disruptive behavior committee meeting attendance

• Order of Behavioral Restriction and patient notification documentation

• Completion of training