Comprehensive Healthcare Inspection of the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Louis A. Johnson VA Medical Center and multiple outpatient clinics in West Virginia. The inspection covered key clinical and administrative processes associated with promoting quality care, focusing on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; 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 virtual CHIP visit, medical center leaders had worked together for seven weeks; all were from other VA facilities and in acting executive roles. The OIG identified multiple recent leadership transitions and vacancies in quality management and equal employment opportunity roles. Employee survey data identified opportunities to improve staff perceptions of leaders and the workplace. Medical center leaders shared observations of staff resistance and guarding, and described changes implemented to improve morale and psychological safety. Overall, patients appeared satisfied with the care received. Leaders were generally knowledgeable about Strategic Analytics for Improvement and Learning data and should continue to take actions to sustain and improve performance and employee and patient satisfaction. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures involved follow-up from a previous OIG report on care and oversight deficiencies. The OIG Rapid Response team was on site for follow-up during the week of the OIG CHIP virtual visit. The OIG issued five recommendations for improvement in three areas: (1) Quality, Safety, and Value • Systems redesign and improvement coordinator designation • Surgical work group attendance (2) Care Coordination • Inter-facility transfer documentation • Nurse-to-nurse communication (3) High-Risk Processes • Disruptive behavior training