Comprehensive Healthcare Inspection of the Memphis VA Medical Center in Tennessee

Report Information

Issue Date
Closure Date
Report Number
21-03310-54
VISN
9
State
Arkansas
Mississippi
Tennessee
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
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 Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Memphis VA Medical Center in Tennessee. This evaluation focused on five key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care • Mental health (emergency department and urgent care center prevention initiatives) Survey results highlighted opportunities for executive leaders to improve patient satisfaction. The OIG issued six recommendations for improvement in two areas: 1. Medical staff privileging • Ongoing Professional Practice Evaluation processes 2. Environment of care • Patient care area inspections • Biohazard signage • Area designations • Video recording

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)
Closure Date: 7/18/2023
The Chief of Staff determines any additional reasons for noncompliance and makes certain that service chiefs include service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2023
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs’ recommendations to continue licensed independent practitioners’ privileges are based, in part, on Ongoing Professional Practice Evaluation data.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/1/2023

The Medical Center Director determines any additional reasons for noncompliance and makes certain the Comprehensive Environment of Care Coordinator or designee schedules and ensures completion of environment of care inspections in patient care areas at the required frequency or maintains documentation to support pandemic-related postponement.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2023
The Medical Center Director determines the reasons for noncompliance and ensures staff post signage in all areas where biohazards are present.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2023
The Medical Center Director determines the reasons for noncompliance and ensures the Chief of Police, Privacy Officer, and chiefs of programs identify medical center areas as a treatment, secure, personal, or other area.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2023
The Medical Center Director determines the reasons for noncompliance and ensures leaders comply with VHA requirements for signage and camera-recording, based on area designations.