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Comprehensive Healthcare Inspection of the Tennessee Valley Healthcare System in Nashville

Report Information

Issue Date
Report Number
21-03312-114
VISN
9
State
Kentucky
Tennessee
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Patient Safety
Medical Staff Privileging Credentialing
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
8
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
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

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Executive Director determines the reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.
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 ensures staff complete final peer reviews within 120 calendar days or approves a written extension request.

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 ensures that for all patient safety events assigned an actual or potential safety assessment code score of three, the Patient Safety Manager conducts an individual root cause analysis or includes the events in an aggregate review.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs use Focused Professional Practice Evaluation criteria that are defined in advance and accepted by the practitioners.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee reviews professional practice evaluations for licensed independent practitioners’ privileging requests and documents the review in meeting minutes.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs establish service-specific criteria for reprivileging decisions.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs recommend reprivileging based, in part, on Ongoing Professional Practice Evaluations completed by practitioners with similar training and privileges.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Deputy Health System Director evaluates and determines any additional reasons for noncompliance and ensures staff identify and minimize physical environmental risks to reduce suicide or suicide attempts in acute inpatient mental health units.