Comprehensive Healthcare Inspection Program Review of the VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska

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 Nebraska-Western Iowa Health Care System (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Credentialing and Privileging; Quality, Safety, and Value; Environment of Care (EOC); Medication Management: Controlled Substances Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The OIG also provided crime awareness briefings to 45 employees. The facility has generally stable executive leadership and active engagement with employees and patients as evidenced by high satisfaction scores. Organizational leaders support patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the facility through active stakeholder engagement). The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. The senior leadership team was knowledgeable about selected SAIL metrics likely contributing to the most current 5-star ranking. The OIG noted findings in five areas of clinical operations reviewed and issued seven recommendations that are attributable to the Facility Director, Chief of Staff, Nurse Executive, and Associate Director. The identified areas with deficiencies are: (1) EOC • EOC rounds attendance • Infection prevention/control goals and identification of risks (2) Medication Management: Controlled Substances Inspection Program • One-day reconciliations during inspections • Pharmacy 72-hour inventories (3) Long-Term Care: Geriatric Evaluations • Program oversight • Nursing assessments (4) Women’s Health: Mammography Results • Communication of test results to patients