Comprehensive Healthcare Inspection of the VA Salt Lake City Health Care System in Utah

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 Salt Lake City 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’s inspection, the Chief of Staff and Director had served in their roles since 2012 and 2017, respectively. However, the remaining three executive leaders had assumed their roles within the past 10 months. Employee survey results demonstrated satisfaction with most executive leaders and maintenance of a work environment where staff felt respected and discrimination was not tolerated. Patient survey results indicated general care satisfaction among male veterans, but opportunities to improve female veterans’ experiences. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable 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 six recommendations for improvement in three areas: (1) Mental Health • Suicide prevention training (2) Care Coordination • Monitoring and evaluation of inter-facility transfers • Transfer form completion • Documentation of active medication lists • Nurse-to-nurse communication (3) High-Risk Processes • Disruptive behavior training