Comprehensive Healthcare Inspection of the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia

Report Information

Issue Date
Report Number
21-00280-89
VISN
6
State
Virginia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Patient Safety
Care Coordination
Major Management Challenges
Healthcare Services
Recommendations
9
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 quality of care delivered in the inpatient and outpatient settings of the Hunter Holmes McGuire VA Medical Center and associated outpatient clinics in Virginia. The inspection covered key clinical and administrative processes that are 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. When the team conducted this inspection, the medical center’s leaders had worked together in their positions for 19 months. Employee survey results highlighted opportunities to improve employee attitudes toward leaders and the workplace, and reduce staff feelings of moral distress. Patient survey results identified opportunities to improve care experiences. Review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify substantial organizational risk factors. The executive leaders spoke knowledgeably within their scope of responsibilities about VHA data and factors contributing to poorly performing quality and efficiency measures. The OIG issued nine recommendations for improvement in three areas: (1) Quality, Safety, and Value • Tracking of improvement capabilities and projects • Peer review processes • Surgical death reviews (2) Care Coordination • Inter-facility transfer monitoring and evaluation • Transfer form completion • Medical record transmission (3) High-Risk Processes • Disruptive behavior committee meeting attendance • Staff training

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 Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign and Improvement Coordinator tracks facility-level improvement capabilities and projects.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete a final peer review within 120 calendar days from the date it is determined that a peer review is needed, or the Medical Center Director approves an extension request in writing.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Surgical Work Group reviews surgical deaths.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff monitor and evaluate inter-facility transfers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure transferring providers complete all required elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent prior to patient transfers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work area.