Report 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 James J. Peters VA Medical Center and related outpatient clinics in New York. The inspection covered key clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus were 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 review, the leadership team had worked together for approximately eight months, although most had served in their positions for more than a year. Employee survey responses revealed that the Associate Director and Associate Director for Patient Care Services/Chief Nurse Executive had opportunities to reduce staff feelings of moral distress, while the Associate Director also had opportunities to improve servant leadership behavior. Patient survey data implied general satisfaction with the care provided; however, opportunities existed to improve inpatient care satisfaction and access to outpatient care. Review of accreditation findings, sentinel events, and disclosures identified organizational risk factors associated with sentinel event and institutional disclosure processes. Executive leaders were knowledgeable within their scope of responsibilities about VHA data and factors contributing to poorly performing quality and efficiency measures.

The OIG issued five recommendations for improvement in two areas:

(1) Quality, Safety, and Value

• Peer review processes

• Surgical workgroup meeting attendance and surgical death reviews

(2) High-Risk Processes

• Disruptive behavior committee meeting attendance

• Staff training