Comprehensive Healthcare Inspection Program Review of the VA St. Louis Health Care System, 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 VA St. Louis Health Care System (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 (CS) 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 58 employees. The Facility has generally stable executive leadership and active engagement with employees as evidenced by satisfaction scores; however, multiple opportunities appear to exist to improve patient satisfaction with care provided. Organizational leaders support patient safety and quality care. 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 appeared knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance of Quality of Care and Efficiency metrics likely contributing to the current “2-Star” rating. The OIG noted findings in four of the eight clinical operations reviewed and issued seven recommendations that are attributable to the Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (2) Environment of Care • Participation in environment of care rounds (3) Medication Management: CS Inspection Program • Alternate CS Coordinator position description includes CS duties • Written CS Inspector appointments • Completion of CS monthly inspections (4) Women’s Health: Mammography Results and Follow-Up • Ordering providers’ notification of all mammography results