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Comprehensive Healthcare Inspection of the Martinsburg VA Medical Center in West Virginia

Report Information

Issue Date
Report Number
21-00287-194
VISN
5
State
Maryland
Virginia
West Virginia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Patient Safety
Care Coordination
Care Coordination
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
9
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 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

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 Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures leaders properly identify adverse events as sentinel events when criteria are met and conduct institutional disclosures, as required.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Health Systems Specialist participates on the VISN Systems Redesign Review Advisory Group.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that core members regularly attend Facility Surgical Workgroup meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff monitor and evaluate all patient transfers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure appropriately privileged providers complete all elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent note prior to patient transfers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff send patients’ active medication lists to receiving facilities during inter-facility transfers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members consistently attend Disruptive Behavior Committee meetings.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that all Employee Threat Assessment Team members complete the required training.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.