Comprehensive Healthcare Inspection of the Salem VA Medical Center in Virginia

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 Salem VA Medical Center in Virginia. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused 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: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior. At the time of the OIG inspection, the medical center’s leaders, except the Assistant Director, had worked together for over one year. Employee satisfaction survey data revealed opportunities for the Associate Director–Patient/Nursing Services to improve employee attitudes toward leaders and the workplace. Overall, results for inpatient and patient-centered medical home experience surveys were generally higher for both genders when compared to the corresponding VHA averages. However, survey results highlighted an opportunity for leaders to improve female patients’ ability to obtain urgent specialty care appointments. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. The leaders were able to speak in depth about actions taken during the previous 12 months to maintain or improve organizational performance, employee satisfaction, or patient experiences. The OIG issued two recommendations for improvement in two areas: (1) Care Coordination • Monitoring and evaluation of patient transfers (2) High-Risk Processes • Disruptive behavior committee meeting attendance