Comprehensive Healthcare Inspection Program Review of the John J. Pershing VA Medical Center, Poplar Bluff, Missouri

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 John J. Pershing 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 Women’s Health: Mammography Results and Follow-Up. The Facility has a relatively new leadership team, and the Chief of Staff position was vacant at the time of the OIG review. Despite this, the OIG noted that the Facility leaders were actively engaged with employees and patients and had implemented proactive programs to improve satisfaction scores. Organizational leaders supported patient safety, quality care, and other positive outcomes. 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 leadership team was knowledgeable about selected SAIL metrics within their scope of responsibility and should continue to take actions to sustain and improve performance of Quality of Care and Efficiency metrics contributing to the current “4-Star” rating. The OIG noted findings in one of the seven areas of clinical operations reviewed and issued two recommendations that are attributable to the Associate Director. The identified area with deficiencies is: Environment of Care • General cleanliness • Emergency power supply system inspection