Comprehensive Healthcare Inspection of the VA New Jersey Health Care System in East Orange

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 New Jersey Health Care System in East Orange. The inspection covered key clinical and administrative processes 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 Director had served in the role since 2017 and some other leaders had been in their positions for over a year. Employee satisfaction survey data revealed opportunities for the Associate Director for Patient Care Services and Associate Director to improve perceptions of leadership and the workplace. Patient experience survey results indicated that males were generally satisfied with their primary care compared to VHA averages. Outpatient survey scores for females were lower than VHA averages. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Leaders were knowledgeable within their scope of responsibilities about VHA data and factors contributing to poor performance on specific Strategic Analytics for Improvement and Learning measures. The OIG issued eight recommendations for improvement in four areas: (1) Quality, Safety, and Value • Systems redesign and improvement coordinator meeting participation • Peer review processes • Surgical work group meetings (2) Registered Nurse Credentialing • Primary source verification (3) Care Coordination • Patient transfer monitoring and evaluation (4) High-Risk Processes • Disruptive behavior committee meeting attendance