Comprehensive Healthcare Inspection of the Charles George VA Medical Center in Asheville, North Carolina

Report Information

Issue Date
Report Number
23-00023-96
VISN
6
State
North Carolina
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
Mental Health
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
5
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 care provided at the Charles George VA Medical Center, which includes multiple outpatient clinics in North Carolina. 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 five recommendations for improvement in three areas:
1.    Quality, safety, and value
•    Sentinel event investigation start dates
•    Root cause analyses

2.    Medical staff privileging
•    Consolidation of credentialing and privileging activities
•    Credentialing and Privileging Manager reports directly to Chief of Staff

3.    Mental health
•    Comprehensive Suicide Risk Evaluation completion

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 Director ensures the Patient Safety Manager documents start dates for sentinel event investigations in the Joint Patient Safety Reporting system.

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

The Director ensures the Patient Safety Manager initiates a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

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

The Director ensures executive leaders consolidate all credentialing and privileging activities into one credentialing and privileging office under the Chief of Staff.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures the Credentialing and Privileging Manager reports directly to the Chief of Staff.

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

The Director ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.