Report Summary

Title: Comprehensive Healthcare Inspection of the Tennessee Valley Healthcare System in Nashville
Report Number: 21-03312-114 Download
Issue Date: 5/16/2023
City/State: Nashville, TN
Murfreesboro, TN
Athens, TN
Athens, TN
Bowling Green, KY
Clarksville, TN
Columbia, TN
Cookeville, TN
Dover, TN
Gallatin, TN
Hopkinsville, KY
McMinnville, TN
Chattanooga, TN
Harriman, TN
Harriman, TN
Arnold Air Force Base, TN
Arnold Air Force Base, TN
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Tennessee Valley Healthcare System, which includes the Nashville VA Medical Center, the Alvin C. York VA Medical Center (Murfreesboro), and multiple outpatient clinics in Kentucky and Tennessee. This evaluation focused on five key operational areas:

• Leadership and organizational risks

• Quality, safety, and value

• Medical staff privileging

• Environment of care

• Mental health (emergency department and urgent care center suicide prevention initiatives)

The OIG issued eight recommendations for improvement in four areas:

1. Leadership and organizational risks

• Institutional disclosures

2. Quality, safety, and value

• Peer review processes

• Patient safety events

3. Medical staff privileging

• Focused and Ongoing Professional Practice Evaluation processes

• Privileging reviews

4. Environment of care

• Environmental risks for suicide

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