Healthcare Facility Inspection of the VA Cincinnati Healthcare System in Ohio

Report Information

Issue Date
Report Number
24-00605-182
VISN
10
State
Indiana
Kentucky
Ohio
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Maintenance and Construction
Patient Care Services Operations
Patient Safety
Staffing
Supplies and Equipment
Major Management Challenges
Healthcare Services
Recommendations
9
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Cincinnati Healthcare System in Ohio. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Primary care
     •    Veteran-centered safety net

The OIG issued nine recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Correct deficiencies found during comprehensive environment of care inspections
     •    Fire drills
     •    Medical equipment inspections and maintenance labels
     •    Clean patient care areas in the Emergency Department
     •    Exit pathways free from obstructions
   2.    Patient safety
     •    Service-level workflows for the communication of test results
     •    Monitoring providers’ communication of urgent, noncritical test results to patients
     •    Root cause analysis actions
     •    Patient safety program
 

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 Director ensures staff correct deficiencies found during comprehensive environment of care rounds or develop an action plan to address them within 14 business days.

No. 2
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to Veterans Health Administration (VHA)

The Director ensures staff conduct fire drills once per shift, per quarter, in each patient area.

No. 3
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to Veterans Health Administration (VHA)

Executive leaders ensure staff inspect all medical equipment timely, and equipment has preventive maintenance labels.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Executive leaders ensure staff properly clean patient care areas in the Emergency Department.

No. 5
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to Veterans Health Administration (VHA)

Executive leaders ensure staff keep exit pathways free from obstructions.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff develop service-level workflows for the communication of test results.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff implement a facility-wide process to monitor providers’ communication of urgent, noncritical test results to patients, and report compliance to an appropriate oversight committee.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Executive leaders ensure staff implement actions from root cause analyses timely, monitor actions for effectiveness and sustained improvement, and report compliance to an appropriate oversight council.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director evaluates the patient safety program, including staffing, to ensure executive leaders receive meaningful patient safety information and improvement project data.