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Comprehensive Healthcare Inspection of Veterans Integrated Service Network 2: New York/New Jersey VA Health Care Network in Bronx, New York

Report Information

Issue Date
Report Number
21-00240-158
VISN
2
State
New York
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Medical Staff Privileging Credentialing
Major Management Challenges
Healthcare Services
Recommendations
4
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

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) 2: New York/New Jersey VA Health Care Network in Bronx, New York, 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 had a stable leadership team, with the Quality Management Officer and Chief, Human Resources Officer permanently assigned prior to the integration of VISNs 2 and 3 in 2015. Selected employee satisfaction survey scores indicated that some VISN leaders had opportunities to improve employee perceptions of servant leadership, respect, discrimination, and psychological safety. Inpatient experience survey scores were lower than VHA national averages but outpatient ratings were higher. The OIG’s review of access metrics and clinical vacancies identified potential organizational risks, with wait times over 20 days at one medical center and clinical vacancies in certain specialties. Opportunities existed to improve executive leadership oversight of facility-level oversight of quality, safety, and value; care coordination; and high-risk processes. The OIG issued four recommendations for improvement in three areas: (1) Medical Staff Credentialing • Physician credentials review process (2) Environment of Care • Annual reviews (3) Women’s Health • Lead women veterans program manager appointment • Annual site visits

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief Medical Officer evaluates and determines additional reasons for noncompliance and makes certain to review the credentials file and approve the VA appointment for physicians who had a potentially disqualifying licensure action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the Emergency Management Committee conducts annual reviews of the Emergency and Continuity of Operations Plans; Hazards Vulnerability Analysis; and Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement, and submits the reviews to executive leaders for approval.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Network Director evaluates and determines any additional reasons for noncompliance and appoints a permanent Veterans Integrated Service Network lead women veterans program manager.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that a lead women veterans program manager conducts yearly visits at each facility in the Veterans Integrated Service Network.