Comprehensive Healthcare Inspection of the VA Connecticut Healthcare System in West Haven

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 Connecticut Healthcare System. 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; Medication Management: Remdesivir Use in VHA; 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 healthcare system’s executive leadership team appeared stable, with all positions permanently assigned. The leaders had worked together for nine months, although two of the leaders had served in their positions for several years. Employee survey data revealed that staff felt generally respected and discrimination was not tolerated. Patients were generally satisfied with the care provided. The OIG’s review of the medical center’s accreditation findings did not identify any organizational risks. However, the OIG identified concerns with the patient safety and risk management program related to identification of sentinel events and completion of institutional disclosures. 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 eight recommendations for improvement in four areas: (1) Quality, Safety, and Value • Surgical work group attendance (2) Mental Health • Suicide prevention training (3) Care Coordination • Patient transfer policy • Patient transfer monitoring and evaluation • Transfer form completion • Nurse-to-nurse communication (4) High-Risk Processes • Disruptive behavior committee attendance • Staff training