Report Summary

Title: Comprehensive Healthcare Inspection of the Washington DC VA Medical Center
Report Number: 21-00288-175 Download
Issue Date: 6/16/2022
City/State: Fort Belvoir, VA
Washington, DC
Charlotte Hall, MD
Camp Springs, MD
Gaithersburg, MD
Lexington Park, MD
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 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