Comprehensive Healthcare Inspection of Veterans Integrated Service Network 20: VA Northwest Health Network in Vancouver, Washington

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 20: VA Northwest Health Network in Vancouver, Washington, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection focused on Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The OIG conducted this unannounced review during concurrent virtual site visits of VISN 20 facilities. The executive leaders had worked together for approximately one month at the time of the OIG virtual review. The VISN office and leaders’ selected employee satisfaction survey averages were generally better than VHA averages, with the exception of the Deputy Network Director and Chief Medical Officer’s scores. Overall, VISN leaders appeared to maintain an environment where employees felt safe bringing forth issues and concerns. Patient experience survey scores were similar to or better than VHA averages. Leaders were knowledgeable within their scope of responsibilities about selected data used in Strategic Analytics for Improvement and Learning models and should continue to sustain and improve performance. The OIG issued four recommendations for improvement in two areas: (1) Medical Staff Credentialing • Credentials file review and approval for physicians with potentially disqualifying licensure actions (2) High-Risk Processes • Sharing of VISN-led facility reusable medical equipment inspection results with executive leaders • Posting of inspection results to the reusable medical equipment SharePoint site • Oversight of facility corrective action plan development and action item tracking