Comprehensive Healthcare Inspection Program Review of the Tennessee Valley Healthcare System, Nashville, Tennessee

The OIG conducted a focused evaluation of the quality of care delivered at the Tennessee Valley Healthcare System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. The OIG also provided crime awareness briefings to 145 employees. The facility has a generally stable executive leadership to support patient safety, quality care, and other positive outcomes; however, opportunities exist to improve both patient experiences and employee attitudes towards leadership. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. The senior leadership team was knowledgeable about selected SAIL metrics but should continue to take significant actions to improve care and performance, particularly Quality of Care and Efficiency metrics likely contributing to the most current 1-star ranking. The OIG noted findings in five of the clinical operations reviewed and issued 15 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) QSV • Ongoing Professional Practice Evaluation data review • Documentation of decisions by physician utilization management advisors (2) Medication Management: Anticoagulation Therapy Management • Patient education specific to the new anticoagulation medications (3) Coordination of Care: Inter-facility Transfers • Transfer data analysis and reporting • Patient transfer documentation • Resident supervision (4) EOC • Frequency and attendance of EOC rounds • General cleanliness • Radiology signage • Panic alarm testing • Locked mental health unit Interdisciplinary Safety Inspection Team training (5) High-Risk Processes: Related to Moderate Sedation • History and physical examinations and pre-sedation assessment components • Provision and documentation of informed consent • Clinical staff training