Comprehensive Healthcare Inspection Program Review of the Fayetteville VA Medical Center, North Carolina

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Fayetteville VA Medical Center (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 Post-Traumatic Stress Disorder (PTSD) Care. The OIG also provided crime awareness briefings to 236 employees. The facility has generally stable executive leadership with a newly approved Assistant Director position to support patient safety, quality care, and other positive outcomes. However, opportunities exist for leadership to improve both employee and patient perceptions of the facility. The OIG’s review of accreditation organization findings, sentinel events, disclosures, and Patient Safety Indicator data did not identify any substantial organizational risk factors. The senior leadership team seemed knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to take actions to improve care and performance of selected SAIL metrics, particularly Quality of Care and Efficiency metrics likely contributing to the current 2-star rating. The OIG noted findings in five areas of clinical operations reviewed and issued 10 recommendations that are attributable to the Facility Interim 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 • Interdisciplinary group participation and review of utilization management data • Completion of annual patient safety report (2) Medication Management: Anticoagulation Therapy • Completion of laboratory tests prior to initiating anticoagulant medications (3) Coordination of Care: Inter-Facility Transfers • Informed consent and identification of transferring and receiving providers • Communication of pertinent patient information to receiving facilities (4) EOC • Locked mental health unit Interdisciplinary Safety Inspection Team training (5) PTSD Care • Suicide risk assessments • Diagnostic evaluations within 30 days of referral