Comprehensive Healthcare Inspection of the VA Maryland Health Care System in Baltimore

Report Information

Issue Date
Report Number
23-00159-160
VISN
5
State
Maryland
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Medical Staff Privileging Credentialing
Mental Health
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
5
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Maryland Health Care System, which includes the Baltimore VA Medical Center (central Baltimore), Loch Raven VA Medical Center (northern Baltimore), Perry Point VA Medical Center (Perry Point), and multiple outpatient clinics in Maryland. This evaluation focused on five key operational areas:
•    Leadership and organizational risks
•    Quality, safety, and value
•    Medical staff privileging
•    Environment of care
•    Mental health (suicide prevention initiatives)

The OIG issued five recommendations for improvement in three areas:
1.    Medical staff privileging
•    Ongoing Professional Practice Evaluation recommendations and results

2.    Environment of care
•    Biohazard sign posting
•    Safe and clean patient care areas
•    Panic alarm testing in the inpatient mental health unit

3.    Mental health
•    Comprehensive Suicide Risk Evaluation completion

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs recommend continued privileges for licensed independent practitioners based on Ongoing Professional Practice Evaluation activities, and the Medical Executive Committee recommends them based on evaluation results.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Deputy Medical Center Director ensures staff post biohazard signs in applicable areas.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Associate Director ensures staff keep patient care areas safe and clean.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Assistant Director ensures staff document VA police response times for panic alarm testing in the inpatient mental health unit.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.