Report 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) 6: VA Mid-Atlantic Health Care Network in Durham, North Carolina, 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 consisted of the acting Network Director, acting Deputy Network Director, acting Chief Medical Officer, and Chief Nursing Officer, who had worked together for about four months. Additional VISN leaders included the Quality Management Officer and acting Human Resources Officer. Selected survey scores related to employees’ satisfaction indicated that leaders were engaged and promoted a culture where employees felt safe bringing forward issues and concerns. Opportunities appeared to exist to improve employee perceptions of servant leadership and reduce feelings of moral distress in the workplace. Patient experience survey scores were lower than VHA averages.

The OIG’s review of access metrics and clinical vacancies identified potential organizational risks at selected facilities, with extended average wait times and clinical vacancies in certain specialties. The executive leaders were knowledgeable within their scope of responsibilities about VHA data and factors contributing to poorly performing quality measures; however, opportunities existed to improve their facility-level oversight of quality, safety, and value; care coordination; and high-risk processes.

The OIG issued five recommendations for improvement in three areas:

(1) Medical Staff Credentialing

• Physician credentials review process

(2) Environment of Care

• Emergency management committee meetings

• Annual review of VISN-wide strengths, weaknesses, priorities, and requirements for improvement

(3) Women’s Health

• Annual site visits

• Staff education gap assessments