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 Samuel S. Stratton VA Medical Center. The inspection covered key clinical and administrative processes 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.
At the time of the inspection, the executive team had worked together in a permanent capacity for approximately six months; however, multiple leaders had served in their positions for more than two years. Employee survey data revealed that staff were satisfied with leadership and felt respected, and discrimination was not tolerated. Overall, outpatient satisfaction survey results were generally higher than VHA averages, but highlighted opportunities to improve access to specialty care appointments. Inpatient survey scores were generally lower than the VHA averages and indicated opportunities to improve experiences for both genders.
The OIG’s review of the medical center’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 taking actions to sustain and improve performance.
The OIG issued 10 recommendations for improvement in three areas:
(1) Quality, Safety, and Value
• Surgical work group attendance
• National Surgery Office quality report review
(2) Care Coordination
• Inter-facility transfer policy
• Transfer monitoring, evaluation, and form completion
• Medication list transmission
• Nurse-to-nurse communication
(3) High-Risk Processes
• Disruptive behavior committee attendance
• Risk assessment participation
• Staff training
The report can be found online here.
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