Comprehensive Healthcare Inspection of the VA Eastern Kansas Health Care System in Topeka

Report Information

Issue Date
Report Number
23-00102-150
VISN
15
State
Kansas
Missouri
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Eastern Kansas Health Care System, which includes the Colmery-O’Neil VA Medical Center (Topeka), Dwight D. Eisenhower VA Medical Center (Leavenworth), and multiple outpatient clinics in Kansas and Missouri. This evaluation focused on five key operational areas:
•    Leadership and organizational risks
•    Quality, safety, and value
•    Medical staff privileging
•    Environment of care
•    Mental health (suicide prevention initiatives)

The OIG issued three recommendations for improvement in the Environment of Care area of review:
•    Walls in good repair
•    Panic and over-the-door alarm testing in the inpatient mental health unit

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures staff maintain a safe environment by keeping walls in good repair.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures staff check over-the-door alarms in the inpatient mental health unit according to the manufacturer’s guidelines.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures staff document VA police response times for panic alarm testing in the inpatient mental health unit.