Comprehensive Healthcare Inspection of the VA Western New York Healthcare System in Buffalo

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 VA Western New York Healthcare System. 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. The healthcare system’s executive leadership team appeared stable, with all positions permanently assigned. Leaders had worked together for about five months, although some had served in their positions for multiple years. Employee survey data revealed opportunities for leaders to improve workplace satisfaction and reduce feelings of moral distress. Patients generally appeared satisfied with their care. The inspection team reviewed accreditation agency findings and disclosures of adverse patient events and did not identify substantial organizational risk factors. However, the OIG identified concerns related to sentinel event identification and reporting. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance. The OIG issued seven recommendations for improvement in four areas: (1) Leadership and Organizational Risks • Identification and reporting of sentinel events (2) Quality, Safety, and Value • Peer review committee recommendation of improvement actions • Surgical work group attendance (3) Care Coordination • Monitoring and evaluation of inter-facility transfers (4) High-Risk Processes • Disruptive behavior committee meeting attendance • Staff training