Comprehensive Healthcare Inspection of the Eastern Oklahoma VA Health Care System, Muskogee, Oklahoma

Report Information

Issue Date
Closure Date
Report Number
18-06510-222
VISN
State
Oklahoma
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
11
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the Eastern Oklahoma VA Health Care System. The inspection covers leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The OIG noted that the facility had a newly appointed leadership team supportive of patient safety and quality care but saw opportunities for improvement of employee satisfaction and trust in the leadership. The presence of organizational risk factors, as evidenced by sentinel events, disclosures, and patient safety indicator data, may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics but should take actions to improve care and performance of selected metrics that are likely contributing to the SAIL “2-star” quality rating. The OIG issued the following 11 recommendations: (1) Medical Staff Privileging • Focused and ongoing professional evaluation processes (2) Environment of Care • Clean/sterile storage (3) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • MST coordinator responsibilities • MST training (4) Geriatric Care: Antidepressant Use among the Elderly • Patient/caregiver education on medications • Medication reconciliation (5) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee core membership • Women Veterans Health Committee reports to the Medical Executive Committee at least quarterly

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2021
The chief of staff makes certain that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The chief of staff makes certain that all focused professional practice evaluations include clearly defined time limitations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The chief of staff confirms that clinical managers share in advance the expectations and outcomes for focused professional practice evaluations for cause with providers and monitors clinical managers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The associate director confirms that unit supervisors remove clean and sterile packaged items from shipping cartons and corrugated boxes prior to stowing in clean or sterile storage areas and monitors unit supervisors’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma-related information to leadership and monitors coordinator’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The facility director ensures that the military sexual trauma coordinator tracks and monitors the screening, referral, and treatment services provided to veterans and monitors coordinator’s compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2021
The facility director confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The chief of staff makes certain that clinicians provide education to the patient and/or caregiver about the risks/benefits, potential interactions, and side effects of newly prescribed medications and monitors clinicians’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The chief of staff ensures clinicians maintain and communicate accurate patient medication information in patients’ electronic health record and reconcile medications and monitors clinicians’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2021
The facility director confirms that the Women Veterans Health Committee includes required core members and monitors the committee’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The facility director makes certain that the Women Veterans Health Committee reports at least quarterly to the Medical Executive Committee.