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 Syracuse VA Medical Center and multiple outpatient clinics in New York. 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 inspection, the medical center’s executive leadership team appeared stable, with all positions permanently assigned. Leaders had worked together almost five months, although some had served in their positions for more than five years. Employee survey data revealed opportunities for leaders to improve servant leadership and decrease employees’ feelings of moral distress. Patients generally appeared satisfied with the care provided. The OIG’s review of the accreditation findings did not identify any organizational risk factors. However, the OIG noted concerns related to patient safety and risk management. 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 three areas:

(1) Leadership and Organizational Risks

• Sentinel events and institutional disclosures

(2) Quality, Safety, and Value

• Systems redesign and improvement coordinator meeting participation

• Surgical work group administration and data analysis

(3) High-Risk Processes

• Disruptive behavior committee meeting attendance

• Staff training