Comprehensive Healthcare Inspection Program Review of the Oklahoma City VA Health Care System, Oklahoma

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Oklahoma City Health Care System (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health Care: Posttraumatic Stress Disorder Care; Long-term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The Facility had generally stable executive leadership since December 2017 and active engagement with employees as evidenced by satisfaction scores. However, opportunities exist to improve patient experiences. Although the OIG noted concern with the number of sentinel events and disclosures, Facility leaders reported reviewing each event, taking corrective actions, and developing preventive measures to improve performance. The OIG reviewed accreditation agency findings, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results and did not identify any substantial organizational risk factors. The leadership team was knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics that are likely contributing to the “3-Star” rating. The OIG noted findings in two of the eight areas of clinical operations reviewed and issued two recommendations that are attributable to the Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Utilization management data review (2) Long-term Care: Geriatric Evaluations • Program oversight and evaluation