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Comprehensive Healthcare Inspection of Veterans Integrated Service Network 5: VA Capitol Health Care Network in Linthicum, Maryland

Report Information

Issue Date
Report Number
21-00239-180
VISN
5
State
District of Columbia
Maryland
West Virginia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Medical Staff Privileging Credentialing
Major Management Challenges
Healthcare Services
Recommendations
1
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 leadership performance and oversight by Veterans Integrated Service Network (VISN) 5: VA Capitol Health Care Network in Linthicum, Maryland, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection also focused on COVID-19: Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Mental Health: Suicide Prevention; Care Coordination: Inter-facility Transfers; and Women’s Health: Comprehensive Care. The executive leaders, who had worked together since August 2020, had spent much of their time and efforts on improving care and leadership at the Louis A. Johnson VA Medical Center following an OIG criminal investigation of a VA nursing assistant who was convicted and sentenced for the murder of seven veterans. Leaders reported taking actions such as ensuring staff completed Morbidity and Mortality reviews, evaluating quality of care through an Administrative Investigation Board, and monitoring hiring and background check processes. Selected survey scores related to employee satisfaction with VISN leaders generally exceeded VHA averages; however, the Deputy Network Director’s servant leadership score was lower than the VHA average. VISN patient experience survey scores were similar to VHA averages, except for inpatient care satisfaction at selected VISN 5 facilities. The OIG identified potential risk factors including mental health wait times at selected facilities over 20 days, higher rates of clinical vacancies, and challenges with facility hiring support and retention of human resources staff. The Network Director, Chief Medical Officer, and Quality Management Officer/Chief Nursing Officer had opportunities to improve oversight of facilities’ quality, safety, and value; care coordination; and high-risk processes. The OIG issued one recommendation for improvement: (1) Medical Staff Credentialing • Physician credentials review process

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 Chief Medical Officer determines the reason for noncompliance, reviews the credentials file, and approves the VA appointment for physicians who had a potentially disqualifying licensure action.