Comprehensive Healthcare Inspection of the Charles George VA Medical Center in Asheville, North Carolina

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 Charles George VA Medical Center in Asheville, North Carolina. The inspection covers key clinical and administrative processes associated with promoting quality care, focusing 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: Interfacility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior. At the time of the OIG inspection, the acting Director had been in the position for two days, but the Associate Director for Patient Care Services/Nurse Executive had been in the role for over 18 years, with other leaders in their roles for over a year. Employee survey responses demonstrated satisfaction with leadership and the workplace. Patient experience survey data implied satisfaction with the care provided, and selected survey results were generally more favorable than those for VHA patients nationally. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were knowledgeable within their scope of responsibilities and tenure about selected VHA data used by the Strategic Analytics for Improvement and Learning models. The OIG issued five recommendations for improvement in two areas: (1) Care Coordination • Inter-facility patient transfer monitoring and evaluation • Transfer form completion • Medication list transmission (2) High-Risk Processes • Disruptive behavior committee meeting attendance • Staff training