Comprehensive Healthcare Inspection of the Washington DC VA Medical Center

Report Information

Issue Date
Report Number
21-00288-175
VISN
5
State
District of Columbia
Maryland
Virginia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Suicide Prevention
Care Coordination
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
9
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 quality of care delivered in the inpatient and outpatient settings of the Washington DC VA Medical Center and multiple outpatient clinics in Maryland, Virginia, and Washington, DC. The inspection covers key clinical and administrative processes that are 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. Medical center leaders had worked together for over three months at the time of the OIG virtual inspection, although several had served in their positions for more than a year. Employee satisfaction survey scores were generally better than VHA averages. Patient experience survey data were mostly lower than VHA averages, highlighting opportunities to improve both outpatient and inpatient care. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures identified concerns with sentinel event and institutional disclosure processes. Medical center leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance. The OIG issued nine recommendations for improvement in six areas: (1) Leadership and Organizational Risks • Sentinel events and institutional disclosures (2) Quality, Safety, and Value • Systems redesign and improvement coordinator (3) Registered Nurse Credentialing • Primary source verification (4) Mental Health • Suicide safety plan training (5) Care Coordination • Inter-facility transfer monitoring and evaluation • Nurse-to-nurse communication (6) High-Risk Processes • Employee threat assessment team • Disruptive behavior committee meeting attendance • Staff training

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 Executive Director evaluates and determines reasons for noncompliance and ensures leaders identify adverse events as sentinel events when criteria are met and conduct institutional disclosures as required.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Executive Director evaluates and determines any additional reasons for noncompliance and designates a systems redesign and improvement coordinator.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Executive Director evaluates and determines any additional reasons for noncompliance and makes certain that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director, Clinical Services evaluates and determines any additional reasons for noncompliance and ensures staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director, Clinical Services and Associate Director, Patient Care Services evaluate and determine reasons for noncompliance and ensure staff monitor and evaluate all inter-facility transfers as part of VHA’s Quality Management Program.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director, Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Executive Director evaluates and determines any additional reasons for noncompliance and ensures Employee Threat Assessment Team meetings are held and members complete training, as required.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director, Clinical Services and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.