Comprehensive Healthcare Inspection Program Review of the Gulf Coast Veterans Health Care System, Biloxi, Mississippi

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Gulf Coast Veterans Health Care System (Facility). The review covered key processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Credentialing and Privileging; 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. At the time of our site visit, the Facility leaders were still adjusting to the January 2018 assignment of the Director and Chief of Staff and were actively working to improve employee satisfaction and the patient experience. The leaders appeared to support efforts related to quality care, but the presence of organizational risk factors may contribute to future lapses in patient safety unless corrective processes are implemented and continuously monitored. The leadership appeared knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to take significant actions to improve care and performance of selected Quality of Care and Efficiency metrics that are likely contributing to the “1-Star” rating. The OIG issued 13 recommendations that are attributable to the Director, Chief of Staff, and Associate Director. Identified areas with deficiencies are: (1) QSV • Interdisciplinary review of utilization management data • Annual patient safety reports (2) Credentialing and Privileging • Approval of clinical privileges by executive leaders • Focused and Ongoing Professional Practice Evaluation processes (3) EOC • EOC rounds attendance • Expiration statements on sterile surgical instruments (4) Medication Management: CS Inspection Program • Annual physical security survey • CS Coordinator position description • Monthly inspections of CS storage areas • Same day completion of CS physical inventories • CS monthly physical counts (5) Mental Health Care: Post-Traumatic Stress Disorder Care • Suicide risk assessments