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

Report Information

Issue Date
Report Number
23-00012-136
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
Medical Staff Privileging Credentialing
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Martinsburg VA Medical Center and multiple outpatient clinics in Maryland, Virginia, and West Virginia. This evaluation focused on five key operational areas:
•    Leadership and organizational risks
•    Quality, safety, and value
•    Medical staff privileging
•    Environment of care
•    Mental health (suicide prevention initiatives)

The OIG issued three recommendations for improvement in two areas:
1.    Medical staff privileging
•    Ongoing Professional Practice Evaluations

2.    Environment of care
•    Expired/outdated inventory in clean and sterile stockrooms

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 Chief of Staff ensures service chiefs recommend continued privileges based on Ongoing Professional Practice Evaluation activities

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures the Executive Committee of the Medical Staff/Credentials Committee recommends continuation of licensed independent practitioners’ privileges based on Ongoing Professional Practice Evaluation results.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures staff check inventory in clean and sterile storerooms and remove expired or outdated items.