Comprehensive Healthcare Inspection of the Louis Stokes Cleveland VA Medical Center, Ohio

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Louis Stokes Cleveland VA Medical Center, covering leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility’s executive leadership team appeared relatively stable. Leaders seemed actively engaged with employees and patients and were working to sustain and further improve satisfaction levels. In the review of the facility’s accreditation findings and disclosures, the OIG identified organizational risks with sentinel events related to surgical procedures and patient safety indicators. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to sustain and improve performance of measures contributing to the facility SAIL “5-star” and CLC “3-star” quality ratings. The OIG issued 10 recommendations for improvement: (1) Quality, Safety, and Value • Implementation of peer review improvement actions • Peer review of all applicable deaths within 24 hours of admission • Interdisciplinary review of utilization management data • Cardiac life support certifications (2) Environment of Care • Medication administration safety • Mental health seclusion room flooring (3) Military Sexual Trauma (MST) Follow-up and Staff Training • MST mandatory training (4) Antidepressant Use among the Elderly • Patient/caregiver education on newly prescribed medications and evaluation of their understanding (5) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership (6) Emergency Departments and Urgent Care Center Operations • Emergency department signage