Comprehensive Healthcare Inspection of the Beckley VA Medical Center in West Virginia

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 Beckley VA Medical Center and two outpatient clinics in West Virginia. The inspection covered key clinical and administrative processes that are associated with promoting quality care. This inspection 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 OIG’s inspection, the medical center’s executive leadership team had worked together for over one year. Employee survey data revealed general satisfaction with leaders. However, opportunities appeared to exist for the Chief of Staff to improve employees’ perceptions toward leaders and the workplace, and for the Chief of Staff, Associate Director/Patient Care Services, and Associate Director to reduce staff feelings of moral distress at work. Patient experience survey scores implied satisfaction with the care provided, but highlighted opportunities for leaders to improve female patients’ experiences with specialty care providers. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable within their scope of responsibility about selected Strategic Analytics for Improvement and Learning model measures and should continue to take actions to sustain and improve performance. The OIG issued four recommendations for improvement in four areas: (1) Quality, Safety, and Value • Surgical workgroup meetings (2) Mental Health • Suicide safety plan training (3) Care Coordination • Medication list transmission (4) High-Risk Processes • Prevention and management of disruptive behavior training