Report Summary

Title: Comprehensive Healthcare Inspection of the VA NY Harbor Healthcare System in New York
Report Number: 21-00299-162 Download
Issue Date: 5/26/2022
City/State: Brooklyn, NY
New York, NY
Queens, NY
Staten Island, NY
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

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 York Harbor Healthcare System. The inspection covered key clinical and administrative processes associated with promoting quality care, focusing 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 OIG inspection, the system’s three permanently assigned leaders had worked together for over four years. However, the leadership team also had two vacant positions and one position that was detailed after a two-and-a-half-year vacancy. Employee satisfaction survey scores for leaders were generally similar to or better than VHA averages. Outpatients appeared satisfied with their care, although overall and gender-specific inpatient survey results were lower than VHA averages. The OIG found deficiencies with identifying sentinel events and conducting institutional disclosures. Additionally, there were repeat findings from the June 2017 comprehensive healthcare inspection related to inter-facility transfers. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue taking actions to sustain and improve performance.

The OIG issued eight recommendations for improvement in five areas:

(1) Leadership and Organizational Risks

• Sentinel events and institutional disclosures

(2) Quality, Safety, and Value

• Peer reviews

(3) Mental Health

• Staff suicide safety plan training

(4) Care Coordination

• Inter-facility transfer forms

(5) High-Risk Processes

• Disruptive behavior committee attendance

• Orders of Behavior Restriction

• Staff training

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