Comprehensive Healthcare Inspection of the VA Puget Sound Health Care System in Seattle, Washington

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 VA Puget Sound Health Care System, which includes the Seattle and American Lake (Tacoma) divisions and multiple outpatient clinics in Washington. The inspection covers key clinical and administrative processes 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. At the time of the OIG virtual review, the executive team had worked together for 16 months. The Director and the Chief of Staff had served since 2017, the Deputy Director for Patient Care Services and Associate Director had been in their positions since 2018, and the Deputy Director had served since 2019. Survey data indicated opportunities to improve employee satisfaction and reduce feelings of moral distress. Patient survey results showed that individuals were generally less satisfied with their care compared to VHA averages. Leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and actions taken during the previous 12 months to maintain and improve performance. The OIG issued 21 recommendations for improvement in six areas: (1) Quality, Safety, and Value • Committee processes • Protected peer review • Patient safety • Root cause analyses (2) Medical Staff Privileging • Focused and ongoing professional practice evaluations • Provider exit reviews (3) Medication Management • Aberrant behavior risk assessment • Urine drug testing • Informed consent • Patient follow-up (4) Care Coordination • Goals of care conversations • Life sustaining treatment decisions progress notes (5) High-Risk Processes • Climate control • Staff training and competencies • Monthly continuing education