Comprehensive Healthcare Inspection of the Durham VA Health Care System in North Carolina

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 Durham VA Health Care System in North Carolina. The inspection covered key clinical and administrative processes that are 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 review, the executive team had worked together in a permanent capacity for four months; however, the Executive Director and the Chief of Staff had served in their positions for over three years. Healthcare system leaders had recently received approval and started recruiting for a second assistant director. Employee survey data revealed satisfaction with leadership, but highlighted opportunities to reduce employees’ feelings of moral distress at work. Selected patient survey results implied lower satisfaction than the VHA average and highlighted opportunities to improve inpatient and outpatient care experiences. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures of adverse patient events did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance. The OIG issued eight recommendations for improvement in four areas: (1) Registered Nurse Credentialing • Primary source verification of licenses (2) Mental Health • Suicide prevention training (3) Care Coordination • Transfer monitoring and evaluation • Transfer form completion • Medication list transmission (4) High-Risk Processes • Disruptive behavior committee attendance • Patient notification of Orders of Behavioral Restriction • Staff training