Comprehensive Healthcare Inspection Program Review of the Tomah VA Medical Center, Wisconsin

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 Tomah VA Medical Center (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; and Womens Health: Mammography Results and Follow-Up. The OIG also provided crime awareness briefings to 74 employees. The Facility currently has stable executive leadership and active engagement with employees and patients, as evidenced by satisfaction scores. The leaders are improving patient satisfaction and had expanded selected programs and services. However, the OIG noted deficiencies with the Leadership Quality Council’s multidisciplinary team review and analysis of aggregated data. The OIG’s review of accreditation organization findings, sentinel events, 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 but should continue to take actions to improve care and performance of selected SAIL metrics, particularly Quality of Care and Efficiency metrics likely contributing to the “3-Star” rating. The OIG noted findings in one area of clinical operations reviewed and issued two recommendations. The identified area with deficiencies are: Medication Management: Controlled Substances Inspection Program • Annual physical security survey deficiencies • Controlled substances reconciliation