Comprehensive Healthcare Inspection Program Review of the Martinsburg VA Medical Center, West Virginia

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Martinsburg VA Medical Center (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Credentialing and Privileging; Quality, Safety, and Value; Environment of Care (EOC); Medication Management: Controlled Substances (CS) Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The OIG also provided crime awareness briefings to 67 employees. The Facility has generally stable executive leadership and active engagement with employees and patients. Organizational leaders support patient safety, quality care, and other positive outcomes. The OIG’s review of accreditation organization findings, sentinel events, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors; however, the Facility does not have a process established for the collection, tracking, and/or analysis of relevant information related to institutional disclosures. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics likely contributing to the current 3-star rating. The OIG noted findings in four of the clinical operations reviewed and issued five recommendations that are attributable to the Facility Director, Acting Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Privilege-specific criteria developed and utilized for Focused Professional Practice Evaluations • Service-specific criteria developed and implemented for Ongoing Professional Practice Evaluations (2) EOC • Attendance during EOC rounds (3) Medication Management: CS Inspection Program • Appropriate verifications of CS orders (4) Women’s Health: Mammography Results and Follow-Up • Electronic linking of results to radiology order