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 Harry S. Truman Memorial Veterans’ Hospital in Columbia, Missouri and multiple outpatient clinics. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; 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. The executive leadership team had worked together for two months prior to the OIG visit. Survey results revealed that employees were generally satisfied with executive leaders. Patient experience survey data, including both male and female satisfaction scores, indicated that patients were generally satisfied with their care. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. In addition, the executive leaders were knowledgeable within their scope of responsibilities about VHA data used by the Strategic Analytics for Improvement and Learning models. The OIG issued 14 recommendations for improvement across seven areas: (1) Quality, Safety, and Value • Utilization management processes • Root cause analysis processes (2) Medical Staff Privileging • Ongoing professional practice evaluations • Provider exit review forms (3) Medication Management • Behavior risk assessment • Urine drug testing • Informed consent • Follow-up after therapy initiation (4) Mental Health • Annual suicide prevention training (5) Care Coordination • Life sustaining treatment decisions progress notes • Multidisciplinary committee establishment (6) Women’s Health • Advisory Committee For Women Veterans membership (7) High-Risk Processes • Staff competency assessments
Columbia, MO
United States
