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 Fayetteville VA Coastal Health Care System. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; 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 system’s executive leadership team appeared stable, with all positions permanently assigned. The leaders had worked together for over one year. Employee satisfaction survey results indicated that the Chief of Staff had opportunities to improve staff attitudes toward the workplace. Scores related to leaders’ listening, respect, trust, favoritism, and response to concerns were lower than the VHA averages, except for the Associate Director, whose score was significantly higher. Patients generally appeared less satisfied with their care than VHA national averages. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. The Director and Chief of Staff were knowledgeable within their scope of responsibilities about VHA data and system-level factors contributing to specific poorly performing Strategic Analytics for Improvement and Learning measures. However, the Associate Director of Patient Care Services and Associate Director had opportunities to increase their knowledge of these factors.
The OIG issued seven recommendations for improvement in three areas:
(1) Quality, Safety, and Value
• Surgical work group meetings and attendance
(2) Care Coordination
• Transfer documentation
• Active medication list transmission
• Nurse-to-nurse communication
(3) High-Risk Processes
• Disruptive behavior committee attendance
• Staff training
The report can be found online here.
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