Comprehensive Healthcare Inspection of the VA Southern Oregon Rehabilitation Center and Clinics, White City, Oregon

Report Information

Issue Date
Closure Date
Report Number
19-00052-54
VISN
State
Oregon
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
5
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the VA Southern Oregon Rehabilitation Center and Clinics, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; and Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up. The facility’s leadership team appeared relatively new, having worked together for six weeks, as of the week of the OIG’s visit. Selected survey scores revealed opportunities for the associate director to improve employee satisfaction and provide a safe workplace environment where employees feel comfortable with bringing forth issues or ethical concerns. Opportunities also exist for leaders to improve patient satisfaction. Review of accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. The leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to act to improve performance of measures contributing to the SAIL “3-star” quality rating. The OIG issued five recommendations for improvement: (1) Quality, Safety, and Value • Root cause analysis processes (2) Medical Staff Privileging • Ongoing professional practice evaluation processes (3) Antidepressant Use among the Elderly • Patient/caregiver education and evaluation of understanding • Medication reconciliation (4) Abnormal Cervical Pathology Results Notification and Follow-up • Patient notification of abnormal results

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The facility director ensures the patient safety manager incorporates all required elements, including consideration of relevant literature and implementation date for action items, into root cause analyses and submits completed analyses to the National Center for Patient Safety within 45 days and monitors the patient safety manager’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2020
The chief of staff ensures the service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The chief of staff confirms that clinicians provide and document patient and/or caregiver education and evaluate understanding of education provided for newly prescribed medications and monitors clinicians’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The chief of staff makes certain that clinicians review and reconcile medications and monitors clinicians’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The chief of staff makes certain that ordering providers communicate abnormal cervical pathology results to patients within the required time frame and monitors providers’ compliance.