Comprehensive Healthcare Inspection Program Review of the VA Black Hills Health Care System, Fort Meade, South Dakota

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 Black Hills 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; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 151 employees. Organizational leadership supports patient safety, quality care, and other positive outcomes; however, the facility leaders have opportunities to improve employee satisfaction. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to improve performance of the Quality of Care and Efficiency metrics likely contributing to the current 4-star SAIL rating. OIG noted findings in three of the six areas of clinical operations reviewed and issued six recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Coordination of Care: Inter-Facility Transfers • Inter-facility patient transfer data analysis and reporting (2) EOC • EOC rounds attendance • Locked mental health (MH) unit environmental safety • Locked MH unit employee and Interdisciplinary Safety Inspection Team training (3) High-Risk Processes: Moderate Sedation • Assessment of patients’ previous adverse experiences with sedation • Use of checklist for timeout procedure