Comprehensive Healthcare Inspection of the Oklahoma City VA Health Care System in Oklahoma

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 Oklahoma City VA Health Care System. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior. The healthcare system’s executive leadership team appeared stable; all positions were permanently assigned, and the team had worked together for over two years. The Director, who was assigned in June 2016, was the most tenured leader. The Assistant Director, assigned in May 2018, was the newest executive leader. Employee survey data revealed opportunities for the Associate Director of Patient Care Services, Associate Director, and Assistant Director to improve employee feelings of moral distress at work. Patient experience survey results highlighted challenges with outpatient care. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance. The OIG issued five recommendations for improvement in four areas: (1) Registered Nurse Credentialing • Primary source verification of registered nurses’ licenses (2) Mental Health • Suicide prevention training (3) Care Coordination • Monitoring and evaluation of patient transfers (4) High-Risk Processes • Disruptive behavior committee attendance • Staff training