Report Summary

Title: Descriptive Analysis of Select Performance Indicators at Two Healthcare Facilities in the Same Veterans Integrated Service Network
Report Number: 20-02899-22 Download
Issue Date: 11/16/2021
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

The OIG conducted a review of select aspects of operations and performance at two Veterans Health Administration (VHA) facilities in the same Veterans Integrated Service Network (VISN) that historically ranged from lower performing (Facility A) to higher performing (Facility B).

Facilities are usually identified, but the OIG is not disclosing facility names in this report. Given that the focus was on comparing performance characteristics, and not a comprehensive inspection, it was determined not to identify each one.

In general, the OIG found that both facilities approached and addressed many patient safety and quality-of-care issues similarly. However, after an in-depth review of data, policies, governance structures, and leadership interviews, the OIG found several factors directly shaped each facility’s ability to accomplish progressively higher performance. The two broad factors were (1) leadership and (2) integration of an effective quality, safety and value (QSV) program and high-reliability organization (HRO) principles. Facility culture and human resource-related considerations affected operations and performance.

Most facilities can and should identify, evaluate, and address opportunities to improve patient care and safety within their organizations. VHA facilities that have experienced high leadership turnover and challenges recruiting permanent, high-caliber managers and leaders may benefit from more proactive VISN and VHA support. A careful examination of leadership, strength of the QSV program, and the integration of HRO principles may reveal underlying themes and additional opportunities for improvement.

In that this was not a traditional compliance or quality review, the OIG did not make formal recommendations. Rather, the OIG identified opportunities for VISNs to provide meaningful and timely assistance to both struggling and better performing facilities and provided eight suggestions for VISNs to consider. Those suggestions relate to mentors; external evaluation and development teams, leadership assignment, and development and succession planning; quality- and safety-related policy updates; staffing methodology; and meeting minute documentation.