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Comprehensive Healthcare Inspection of the West Palm Beach VA Medical Center in Florida

Report Information

Issue Date
Report Number
21-00272-283
VISN
8
State
Florida
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Major Management Challenges
Healthcare Services
Recommendations
2
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 West Palm Beach VA Medical Center. The inspection covered 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; 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. At the time of the OIG review, the leadership team had worked together for just over two months. All positions were permanently assigned. Employee survey results identified opportunities for improvement but also reflected an environment where staff felt respected and discrimination was not tolerated. Patient survey results, while generally more positive than VHA averages, also highlighted opportunities to improve male inpatient experiences and female patients’ access to routine specialty care appointments. Executive leaders were knowledgeable about selected medical center Strategic Analytics for Improvement and Learning metrics but lacked understanding of community living center metrics. The OIG issued two recommendations for improvement in two areas: (1) Quality, Safety, and Value • Surgical work group attendance (2) High-Risk Processes • Prevention and management of disruptive behavior 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 Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all core members consistently attend Surgical Work Group meetings.
No. 2
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 that employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.