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 Hershel “Woody” Williams VA Medical Center and multiple outpatient clinics in Kentucky, Ohio, and West Virginia. 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.
At the time of the OIG inspection, all leadership positions were permanently assigned and the executive team had worked together for over one year. The Director and Chief of Staff were assigned in February 2014 and June 2020, respectively. Employee survey data revealed an opportunity for the Director to decrease staff feelings of moral distress at work. Patient experience survey scores generally reflected similar or higher care ratings than the VHA averages, although leaders appeared to have an opportunity to improve female patients’ primary care access. The OIG’s review of the medical center’s accreditation findings did not identify any substantial organizational risk factors. However, the OIG identified concerns with conducting institutional disclosures for sentinel events. Executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue efforts to sustain and improve performance.
The OIG issued six recommendations for improvement in four areas:
(1) Leadership and Organizational Risks
• Institutional disclosures
(2) Quality, Safety, and Value
• Systems Redesign Coordinator meeting participation
• Surgical work group meetings
(3) Care Coordination
• Inter-facility transfer form completion
(4) High-Risk Processes
• Disruptive behavior committee meeting attendance
The report can be found online here.
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