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 W.G. (Bill) Hefner VA Medical Center. The inspection covered key clinical and administrative processes that are associated with promoting quality care. This inspection 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.

The medical center’s executive leadership team had worked together for approximately three months, although two leaders had served in their positions for multiple years. The remaining team members were not permanently assigned to their positions. Employee survey responses demonstrated satisfaction with leadership. However, responses also revealed opportunities to reduce staff feelings of moral distress at work. Patient experience survey data highlighted opportunities for leaders to improve experiences in the inpatient and outpatient settings. The OIG’s review of the system’s accreditation findings did not identify any substantial organizational risk factors. However, the OIG identified a concern with leaders conducting institutional disclosures for all sentinel events. Executive leaders were knowledgeable within their scope of responsibilities about VHA data, organizational factors contributing to poor performance on Strategic Analytics for Improvement and Learning measures, actions taken to maintain or improve organizational performance, employee satisfaction, and patient experiences.

The OIG issued four recommendations for improvement in three areas:

(1) Leadership and Organizational Risks

• Institutional disclosures

(2) Quality, Safety, and Value

• Systems Redesign Review Advisory Group participation

• Surgical work group meeting attendance

(3) High-Risk Processes

• Staff training