Comprehensive Healthcare Inspection Program Review of the VA Long Beach Healthcare System, Long Beach, California

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Long Beach Healthcare System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. OIG also provided crime awareness briefings to 151 employees. The facility has generally stable executive leadership to support patient safety and quality care. However, the presence of multiple organizational risk factors, such as adverse event disclosures, reported in-hospital complications, and adverse events following surgeries and procedures, may contribute to future issues of lapses in patient safety unless corrective processes are implemented and continuously monitored. Facility leaders should continue to take actions to improve performance of selected Strategic Analytics for Improvement and Learning metrics, particularly Quality of Care metrics. OIG noted findings in five areas of clinical operations reviewed and issued 14 recommendations that are attributable to the Facility Director, Chief of Staff, Nurse Executive, and Assistant Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Review of Ongoing Professional Practice Evaluation data (2) Medication Management: Anticoagulation Therapy • Employee competency assessments (3) Coordination of Care: Inter-Facility Transfers • Documentation of informed consent and patient stability for transfer • Resident supervision • Communication with accepting facility (4) Environment of Care • General safety and cleanliness • Infection prevention risk assessment • Dirty and used equipment storage • Panic alarm and security surveillance television system testing  (5) Long-Term Care: Community Nursing Home Oversight • Oversight committee membership • Program integration • Cyclical clinical visits