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 Northport VA Medical Center and multiple outpatient clinics in New York. The inspection covered 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 almost five months at the time of the virtual inspection. Employee satisfaction survey scores for the medical center were lower than VHA averages, but scores for the Director were consistently higher than those for VHA and the medical center. Outpatient satisfaction survey results were generally higher than VHA averages but revealed opportunities to improve specialty care experiences for female veterans. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. 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 five recommendations for improvement in four areas:
(1) Quality, Safety, and Value
• Peer review of deaths within 24 hours
(2) Registered Nurse Credentialing
• Primary source verification
(3) Care Coordination
• Nurse-to-nurse communication
(4) High-Risk Processes
• Disruptive behavior committee meeting attendance
• Staff training
The report can be found online here.
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