Comprehensive Healthcare Inspection of the Eastern Oklahoma VA Health Care System in Muskogee

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 Eastern Oklahoma VA Health Care System. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; 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 virtual review, all leadership positions were permanently filled. Survey data revealed opportunities to improve employee perceptions of leadership, reduce feelings of moral distress at work, and reduce fears of retaliation. Patient experience survey data highlighted a need to address outpatient care experiences. The OIG identified concerns with institutional disclosures for sentinel events. Leaders were generally knowledgeable within their scope of responsibilities about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance. The OIG issued 9 recommendations for improvement in 4 areas: (1) Leadership and Organizational Risks • Institutional disclosures for sentinel events (2) Quality, Safety, and Value • Designated systems redesign and improvement coordinator • Surgical work group attendance (3) Care Coordination • Inter-facility transfer form completion • Active medication list transmission (4) High-Risk Processes • Disruptive behavior committee meeting attendance • Patient notification of behavioral restriction order • Staff training