Report Summary

Title: Comprehensive Healthcare Inspection of the James A. Haley Veterans' Hospital in Tampa, Florida
Report Number: 21-00274-289 Download
Issue Date: 10/13/2021
City/State: Tampa, FL
New Port Richey, FL
Lakeland, FL
Brooksville, FL
Zephyrhills, FL
Lecanto, FL
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 James A. Haley Veterans’ Hospital. 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.

At the time of the OIG virtual review, the executive team had worked together for approximately six months. The Associate Director for Patient Care Services, assigned in April 2010, was the most tenured leader. In June 2020, the Director was detailed to the Veterans Integrated Service Network and the Deputy Director and Associate Director were promoted to acting roles as the Director and Deputy Director, respectively.

Employee satisfaction survey responses were generally positive. However, the responses highlighted opportunities for the Associate Director for Patient Care Services and Associate Director to adopt servant leadership traits. Patient experience survey scores were generally similar to or more favorable than the corresponding VHA averages, but leaders could improve access to urgently needed outpatient appointments. The Director, Chief of Staff, and Associate Director for Patient Care Services were generally 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 three recommendations for improvement in two areas:

(1) Quality, Safety, and Value

• Surgical work group review process

(2) High-Risk Processes

• Disruptive behavior committee review process

• Staff training