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Comprehensive Healthcare Inspection of the Miami VA Healthcare System in Florida

Report Information

Issue Date
Report Number
21-00268-273
VISN
8
State
Florida
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Care Coordination
Major Management Challenges
Healthcare Services
Recommendations
5
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 Miami VA 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 system’s executive leadership team appeared stable, with the exception of the associate director for patient care services position. The position had been vacant since April 2019 and was filled by two different interim staff. Employee satisfaction survey data was generally positive. However, scores for the associate director for patient care services role reflected opportunities to improve staff feelings toward leaders and the workplace. Patient experience survey data indicated overall satisfaction with the care provided, but also revealed concerns with specialty care services. The OIG’s review of the medical center’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 • Transfer documentation • Medication list transmission (2) High-Risk Processes • Staff training

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 and Associate Director for Patient Care Services evaluate and determine reasons for noncompliance and make certain that all transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine additional reasons for noncompliance and ensure that staff use the VA Inter-Facility Transfer Form or an equivalent note to document inter-facility transfers.
No. 3
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 referring physicians record all required elements in the electronic health record prior to patient transfers.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine the reasons for noncompliance and ensure staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.
No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.