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Comprehensive Healthcare Inspection of Veterans Integrated Service Network 8: VA Sunshine Healthcare Network in St. Petersburg, Florida

Report Information

Issue Date
Report Number
21-00236-44
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
Medical Staff Privileging Credentialing
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 leadership performance and oversight by Veterans Integrated Service Network (VISN) 8: VA Sunshine Healthcare Network in St. Petersburg, Florida, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection also focused on COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Mental Health: Suicide Prevention; Care Coordination: Inter-facility Transfers; and Women’s Health: Comprehensive Care. The VISN’s executive leadership team had worked together since May 2019. The Chief Financial Officer, who was assigned in 2008, was the most tenured leader. Employee satisfaction survey scores indicated that VISN leaders were engaged and promoted a culture where employees felt safe bringing forward issues and concerns. VISN patient experience survey results were better than the VHA averages for inpatient care and on par with VHA averages for outpatient care. The OIG’s review of access metrics and clinical vacancies identified potential organizational risks. The executive leaders seemed to support efforts to improve and maintain patient safety, quality care, and other positive outcomes. They were also knowledgeable within their scope of responsibilities about selected Strategic Analytics for Improvement and Learning metrics and should continue to take actions to sustain and improve performance. The OIG issued two recommendations for improvement: (1) Medical Staff Credentialing • Physician credential review process (2) Women’s Health • Annual site visit completion

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 Medical Officer evaluates and determines any additional reasons for noncompliance and makes certain to review the credentials files and approve the VA appointments of physicians who had potentially disqualifying licensure actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the Lead Women Veterans Program Manager completes yearly site visits at each facility within the Veterans Integrated Service Network.