Comprehensive Healthcare Inspection of the Kansas City VA Medical Center in Missouri

Report Information

Issue Date
Report Number
19-06850-208
VISN
15
State
Kansas
Missouri
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Medical Staff Privileging Credentialing
Major Management Challenges
Healthcare Services
Recommendations
20
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
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 Kansas City VA Medical Center and multiple outpatient clinics in Kansas and Missouri. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The executive leaders were permanently assigned. Employee satisfaction survey results revealed opportunities for the Associate Director for Patient Care Services to improve employee engagement and empowerment. Patients appeared generally satisfied with the care provided. Review of the facility’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. Executive leaders were generally knowledgeable within their scope of responsibilities contributing to specific poorly performing Strategic Analytics for Improvement and Learning quality measures. However, the OIG noted that only 6 of 29 VHA quality metrics showed high performance compared to other facilities, indicating multiple opportunities exist for improvement. The OIG issued 20 recommendations for improvement in seven areas: (1) Quality, Safety, and Value • Root cause analysis processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit review processes (3) Environment of Care • Medication storage • Clinic privacy (4) Medication Management • Behavior risk assessment • Urine drug testing • Informed consent • Follow-up after therapy initiation • Pain Management Committee processes (5) Mental Health • Suicide prevention training (6) Care Coordination • Life-Sustaining Treatment Decisions Committee processes (7) High-Risk Processes • Risk analysis • Airflow monitoring • Environmental safety • Equipment storage • Staff training

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)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager submits each root cause analysis to the National Center for Patient Safety within the required time frame.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers define in advance, communicate, and document expectations for focused professional practice evaluations in the providers’ profiles.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs’ reprivileging recommendations are based on ongoing professional practice evaluation activities.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Executive Committee of the Medical Staff’s decision to recommend continuation of privileges is based on ongoing professional practice evaluation results. 
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals departing the medical center.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that nursing staff label multidose medication vials with an expiration date upon opening.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that privacy curtains are installed in all examination rooms at the Shawnee VA Clinic.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures a record of visitor access for the information technology room is maintained at the Shawnee VA Clinic.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians complete a behavior risk assessment that includes a history of substance abuse, mental health problems or disorders, and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy. 
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing as required for patients on long-term opioid therapy. 
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently obtain and document informed consent prior to initiating patients on long-term opioid therapy. 
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that clinicians follow up with patients receiving long-term opioid therapy includes an assessment of adherence to the pain management plan of care.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Pain Management Committee monitors the quality of pain assessments and the effectiveness of pain management interventions. 
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all staff receive annual suicide prevention refresher training.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a multidisciplinary life-sustaining treatment decisions committee is established to review all proposed plans. 
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that airflow is monitored in the gastroenterology clinic clean scope rooms.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that damaged flooring or tiles are repaired or replaced in the gastroenterology clean scope storage room.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that high-level disinfected endoscopes are stored properly.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures Sterile Processing Services staff receive monthly continuing education.