Comprehensive Healthcare Inspection Program Review of the Chillicothe VA Medical Center, Ohio

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of Chillicothe 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; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; and Women’s Health: Mammography Results and Follow-Up. The Facility has stable executive leadership and active engagement with employees and patients as evidenced by high satisfaction scores. Organizational leaders appear to support patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the Facility through active stakeholder engagement). The OIG’s review of accreditation organization findings, sentinel events, disclosures, and Patient Safety Indicator data results did not identify any substantial organizational risk factors. Although the leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning metrics and the Facility was rated as “5 Stars” for overall quality, the leaders should continue to take actions to sustain performance and to improve care and performance of poorer performing Quality of Care and Efficiency metrics. The OIG noted findings in two of the seven areas of clinical operations reviewed and issued two recommendations that are attributable to the Chief of Staff. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused Professional Practice Evaluations (2) Women’s Health: Mammography Results and Follow-Up • Electronic linking of mammogram results to the radiology order