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 Martinsburg VA Medical Center. The inspection covered key clinical and administrative processes 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.

At the time of the OIG’s virtual inspection, the medical center’s executive leadership team had worked together for just over one month. Employee survey data revealed opportunities for the Director; Chief of Staff; and Associate Director, Patient Care Services to reduce staff feelings of moral distress at work. Patient experience survey data indicated that leaders had an opportunity to improve female respondents’ inpatient and specialty care experiences. The OIG’s review of the medical center’s accreditation findings did not identify any substantial organizational risk factors. However, the OIG identified concerns related to sentinel events and institutional disclosures. Executive 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 four areas:

(1) Leadership and Organizational Risks

• Sentinel events and institutional disclosures

(2) Quality, Safety, and Value

• Systems Resign and Improvement Program

• Surgical work group attendance

(3) Care Coordination

• Patient transfer monitoring and evaluations

• Inter-facility transfer forms

• Medication list transmission

(4) High-Risk Processes

• Disruptive behavior committee attendance

• Staff training