Comprehensive Healthcare Inspection of the VA Maine Healthcare System in Augusta

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Maine Healthcare System. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior. The leadership team appeared stable, with all the positions permanently assigned. Employee survey data revealed satisfaction with leadership and a workplace where staff felt respected and discrimination was not tolerated. Patient experience survey results highlighted opportunities to improve female veterans’ satisfaction in inpatient and outpatient settings. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures of adverse patient events did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance. The OIG issued eleven recommendations for improvement in three areas: (1) Quality, Safety, and Value • Systems redesign and improvement program process • Peer review quarterly summaries • Surgical work group attendance (2) Care Coordination • Patient transfer policy • Patient transfer monitoring and evaluation • Informed consent • Transfer form completion • Nurse-to-nurse communication (3) High-Risk Processes • Disruptive behavior committee attendance • Disruptive Behavior Reporting System • Staff training