Comprehensive Healthcare Inspection of the Orlando VA Healthcare System in 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 Orlando VA Healthcare System and multiple outpatient clinics in Florida. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection 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. When the team conducted this inspection, the healthcare system’s leaders had worked together for approximately two months, although all but one leader had served in their position for over a year. Two of the five healthcare executive positions were filled in an acting capacity. Employee survey data indicated satisfaction with leaders. Patient experience survey scores for access to urgently needed primary or specialty care appointments were generally lower than VHA national averages. The OIG’s review of the healthcare’s accreditation findings did not identify any substantial organizational risk factors. The OIG identified concerns with identification of sentinel events and completion of institutional disclosures. Executive leaders were knowledgeable within their scope of responsibilities about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance. The OIG issued four recommendations for improvement in three areas: (1) Quality, Safety, and Value • Surgical work group meeting attendance (2) Registered Nurse Credentialing • Primary source verification of nursing licenses (3) High-Risk Processes • Disruptive behavior committee meeting attendance • Staff training