Comprehensive Healthcare Inspection Program Review of the Erie VA Medical Center, Pennsylvania

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Erie 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 OIG also provided crime awareness briefings to 74 employees. The Facility has stable executive leadership and active engagement with employees and patients as evidenced by high satisfaction scores. Organizational leaders 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 did not identify any substantial organizational risk factors. Although the leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics and the Facility is currently rated as “5-Star,” the leaders should continue to take actions to improve or maintain performance of Quality of Care metrics. The OIG noted findings in three of the seven areas of clinical operations reviewed and issued three recommendations that are attributable to the Chief of Staff and Associate Director for Patient Care Services. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Protected peer review process (2) Credentialing and Privileging • Ongoing Professional Practice Evaluation process (3) Environment of Care • Medication administration, storage, and disposal processes