Comprehensive Healthcare Inspection of the VA Butler Health Care Center, Pennsylvania

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the VA Butler Health Care Center, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. During the OIG’s review, two of four executive leaders were serving in an acting capacity. With the exception of the chief of staff’s scores, selected survey scores related to employee satisfaction and trust were generally higher than VHA averages. Patient experience survey scores indicated that patients appeared generally satisfied with leadership and the care provided. Leaders appeared to support efforts to improve and maintain patient safety, quality care, and other positive outcomes. Review of accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning and community living center metrics and should continue to act to sustain and improve performance of measures contributing to the Strategic Analytics for Improvement and Learning “5-star” and community living center “2-star” quality ratings. The OIG issued five recommendations for improvement in the following areas: (1) Medical Staff Privileging • Professional practice evaluation process (2) Military Sexual Trauma Follow-up and Staff Training • Military Sexual Trauma mandatory training (3) Antidepressant Use among the Elderly • Patient/caregiver education and evaluation of understanding • Medication reconciliation (4) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership composition