Comprehensive Healthcare Inspection Program Review of the Ralph H. Johnson VA Medical Center, Charleston, South Carolina

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 Ralph H. Johnson 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; 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 25 employees. The Facility has generally stable executive leadership and active engagement with employees and patients as evidenced by 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, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to maintain Quality of Care and Efficiency metrics likely contributing to the “5-Star” rating. The OIG noted findings in two of the eight areas of clinical operations reviewed and issued four recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are: (1) Environment of Care • Participation in environment of care rounds • Cleanliness of floors in patient care areas • Maintenance of patient care equipment in clinical areas (2) Women’s Health: Mammography Results and Follow-Up • Scanning of mammogram reports