Comprehensive Healthcare Inspection of the Roseburg VA Health Care System in Oregon

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Roseburg VA Health Care System, which includes the Roseburg VA Medical Center and three outpatient clinics in Oregon. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Privileging; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. When the team conducted this inspection, the healthcare system’s leaders had worked together for 16 months, with the most tenured leader permanently assigned in 2016. Survey results revealed opportunities to improve staff feelings of “moral distress” in the workplace. Patients appeared generally satisfied, but there were opportunities to improve the experiences of women veterans. The OIG identified concerns with root cause analysis action implementation and outcomes measurement. Leaders were knowledgeable about employee satisfaction and patient experiences. However, they had opportunities to improve their knowledge of VHA data and/or system-level factors contributing to specific poorly performing Strategic Analytics for Improvement and Learning measures. The OIG issued 13 recommendations for improvement in six areas: (1) Quality, Safety, and Value • Root cause analyses (2) Medical Staff Privileging • Ongoing professional practice evaluations • Provider exit reviews (3) Mental Health • Staff training (4) Care Coordination • Goals of care conversations (5) Women’s Health • Designated women’s health providers • Women veterans health committee (6) High-Risk Processes • Standard operating procedures • Staff training • Monthly staff continuing education