Comprehensive Healthcare Inspection of Veterans Integrated Service Network 7: VA Southeast Network in Duluth, Georgia

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 7: VA Southeast Network in Duluth, Georgia, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection focused on Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The OIG conducted this unannounced visit during concurrent inspections of VISN 7 facilities. In September 2019, VHA reassigned the Network Director and Chief Medical Officer, and appointed acting leaders to fill their roles following reports that a Community Living Center patient was bitten by hundreds of ants. The leadership team had worked together for almost five months at the time of the visit. Selected survey scores regarding employee satisfaction revealed opportunities for the acting Chief Medical Officer to improve attitudes toward leaders and for the Deputy Network Director and Quality Management Officer to improve feelings of moral distress at work. Patient experience survey scores were lower than VHA averages. The VISN leaders have an opportunity to improve employee and patient satisfaction. The leaders seemed to support efforts to improve and maintain patient safety, quality care, and other positive outcomes. The OIG issued seven recommendations for improvement in three areas: (1) Environment of Care • VISN comprehensive environment of care program policy • VISN Emergency Management Committee processes (2) Women’s Health • Quarterly program updates to executive leaders • Annual site visits at each facility • Staff education gap assessments (3) High-Risk Processes • VISN-led facility reusable medical equipment inspection results