Comprehensive Healthcare Inspection Program Review of the Bay Pines VA Healthcare System, Florida

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 Bay Pines VA Healthcare System (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 164 employees. The Facility is moving towards establishing a stable leadership team with the addition of a new Associate Director and Assistant Director since the OIG’s site visit. The OIG also noted 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, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. The senior leadership team was knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics likely contributing to the “3-Star” ranking. The OIG noted findings in four of the clinical operations reviewed and issued four recommendations that are attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are: (1) Environment of Care • Cleanliness of patient care areas (2) Medication Management: Controlled Substances Inspection Program • Alternate Controlled Substances Coordinator (CSC) position description (3) Long-Term Care: Geriatric Evaluations • Comprehensive psychosocial assessments (4) High-Risk Processes: Central Line-Associated Bloodstream Infections • Staff education