Comprehensive Healthcare Inspection of the Sheridan VA Medical Center in Wyoming

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 Sheridan VA Medical Center and multiple outpatient clinics in Wyoming. The inspection covers key clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus were Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; 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. At the time of the OIG review, the leadership team had worked together for over two years. The Director, who was permanently assigned in August 2017, was the most tenured leader. Selected employee survey responses revealed satisfaction with leadership and a workplace where staff felt respected and discrimination was not tolerated. Patient experience survey results were generally higher than VHA averages for male inpatient care, but opportunities for improvement were identified for both genders in outpatient settings. Review of the facility’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. The executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and factors contributing to poorly performing quality and efficiency measures. The OIG issued three recommendations for improvement in three areas: (1) Quality, Safety, and Value • Peer review committee recommendation of improvement actions (2) Registered Nurse Credentialing • Primary source verification of registered nurses’ licenses prior to appointment (3) High-Risk Processes • Disruptive behavior committee attendance