Comprehensive Healthcare Inspection of the VA Maine Healthcare System in Augusta

Submitting OIG:

Report Description:

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 Maine Healthcare System, which includes the Togus VA Medical Center and multiple outpatient clinics in Maine. 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 12 recommendations for improvement in all five areas: 1. Leadership and organizational risks • Sentinel events and institutional disclosures 2. Quality, safety, and value • Root cause analysis for patient safety events 3. Medical staff privileging • Ongoing Professional Practice Evaluation data • Focused Professional Practice Evaluation reporting • VISN oversight of credentialing and privileging processes 4. Environment of care • Environment of care inspections • Panic and over-the-door alarm testing • Maintaining a safe environment • Hazard warning signs • Safe and clean patient care areas 5. Mental health • Comprehensive Suicide Risk Evaluation completion

Date Issued:

Wednesday, April 3, 2024

Agency Reviewed / Investigated:

Department of Veterans Affairs

Submitting OIG-Specific Report Number:

23-00109-121

Component, if applicable:

Veterans Health Administration

Location(s):

United States

Type of Report:

Inspection / Evaluation

Questioned Costs:

Funds for Better Use:

Number of Recommendations:

Report updated under NDAA 5274:

View Document:

Attachment	Size
VAOIG-23-00109-121.pdf	1.65 MB

Additional Details Link:

https://www.vaoig.gov/reports/comprehensive-healthcare-inspection-program/compre…

Related Open Recommendations

Recommendation Number	Recommendation Status	Significant Recommendation
01	Open	Yes
The Medical Center Director ensures leaders identify and evaluate sentinel events and conduct and document institutional disclosures when criteria are met.
02	Open	Yes
The Medical Center Director ensures staff complete a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
03	Open	Yes
The Chief of Staff ensures service chiefs recommend reprivileging for licensed independent practitioners based, in part, on Ongoing Professional Practice Evaluation data.
04	Open	Yes
The Chief of Staff ensures staff report licensed independent practitioners’ Focused Professional Practice Evaluation results to the Clinical Executive Board.
05	Open	Yes
The Veterans Integrated Service Network Chief Medical Officer provides effective oversight of credentialing and privileging processes at the healthcare system.
06	Open	Yes
The Medical Center Director ensures the comprehensive environment of care coordinator schedules environment of care inspections at the required frequency and verifies staff complete and document them.
07	Open	Yes
The Medical Center Director ensures staff document police response times to panic alarm testing in the Inpatient Mental Health Unit.
08	Open	Yes
The Medical Center Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on Inpatient Mental Health Unit sleeping room doors.
09	Open	Yes
The Medical Center Director ensures staff maintain a safe environment in the Inpatient Mental Health Unit.
10	Open	Yes
The Medical Center Director ensures staff post hazard warning signs on all access doors where potentially infectious materials are located.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

Open

Yes

The Medical Center Director ensures leaders identify and evaluate sentinel events and conduct and document institutional disclosures when criteria are met.

Open

Yes

The Medical Center Director ensures staff complete a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

Open

Yes