Comprehensive Healthcare Inspection of the Central Virginia VA Health Care System in Richmond

Report Information

Issue Date
Report Number
23-00104-134
VISN
6
State
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
6
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 Central Virginia VA Health Care System, which includes the Richmond VA Medical Center and multiple outpatient clinics in 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 six recommendations for improvement in three areas:
1.    Quality, safety, and value
•    Recommendations and improvement actions for Level 3 peer reviews

2.    Medical staff privileging
•    Recommendations for privileges based on professional practice evaluation results

3.    Environment of care
•    Temperature- and humidity-controlled storage of reusable medical equipment
•    Clean and safe storage rooms and patient areas
•    Medication access limited to approved staff
•    Availability of feminine hygiene products in restrooms at no cost
 

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 Chief of Staff ensures supervisors communicate the Peer Review Committee’s recommendations for all Level 3 peer reviews to providers and ensure they implement the improvement actions.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Chief of Staff ensures the Medical Executive Council documents its review of licensed independent practitioners’ professional practice evaluations and recommend privileges based on the results.

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

The Executive Director ensures staff store reusable medical equipment in temperature- and humidity-controlled storage locations.

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

The Associate Director ensures staff keep storage rooms and areas used by patients clean and safe.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff limits medication access to approved staff members.

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

The Associate Director ensures all toilet rooms within proximity to areas where pelvic examinations are performed, and all women’s, unisex, and family public restrooms have feminine hygiene products available at no cost.