Comprehensive Healthcare Inspection of the North Florida/South Georgia Veterans Health System in Gainesville, Florida

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 North Florida/South Georgia Veterans Health System, which includes the Malcom Randall VA Medical Center in Gainesville and the Lake City VA Medical Center . 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 assistant director position had been vacant since 2019, with the Deputy Director and the Associate Director, Lake City sharing the responsibilities. All but one of the assigned leaders had worked together for over one year. Employee survey data revealed satisfaction with leadership and a workplace where staff felt respected and discrimination was not tolerated. Selected patient experience scores implied general satisfaction. However, survey results also highlighted opportunities to improve satisfaction for male and female veterans in inpatient and outpatient settings. 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 six recommendations for improvement in four areas: (1) Quality, Safety, and Value • Surgical work group attendance (2) Registered Nurse Credentialing • Primary source verification (3) Care Coordination • Receiving physician identification • Medication list transmission (4) High-Risk Processes • Staff training