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 VA Maryland Health Care System, which includes the Baltimore, Loch Raven, and Perry Point VA Medical Centers, and multiple outpatient clinics in Maryland. The inspection covered key clinical and administrative processes 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 virtual inspection, the healthcare system’s leadership team had worked together for nearly three months, except for the interim Deputy Director, who was assigned one day prior to the inspection. Selected employee survey responses demonstrated satisfaction with leadership and maintenance of an environment where staff felt respected, and discrimination was not tolerated. Patient experience survey data implied general satisfaction with the outpatient care provided, however, leaders had opportunities to improve inpatient care satisfaction. Review of accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. The executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and factors contributing to poorly performing quality and efficiency measures.

The OIG issued eight recommendations for improvement in three areas:

(1) Quality, Safety, and Value

• Peer review processes

(2) Care Coordination

• Patient transfer monitoring and evaluation

• Inter-facility transfer form completion

• Medication list transmission

• Nurse-to-nurse communication

(3) High-Risk Processes

• Staff training