Comprehensive Healthcare Inspection of the Eastern Oklahoma VA Health Care System, Muskogee, Oklahoma

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the Eastern Oklahoma VA Health Care System. The inspection covers leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus 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. The OIG noted that the facility had a newly appointed leadership team supportive of patient safety and quality care but saw opportunities for improvement of employee satisfaction and trust in the leadership. The presence of organizational risk factors, as evidenced by sentinel events, disclosures, and patient safety indicator data, may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics but should take actions to improve care and performance of selected metrics that are likely contributing to the SAIL “2-star” quality rating. The OIG issued the following 11 recommendations: (1) Medical Staff Privileging • Focused and ongoing professional evaluation processes (2) Environment of Care • Clean/sterile storage (3) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • MST coordinator responsibilities • MST training (4) Geriatric Care: Antidepressant Use among the Elderly • Patient/caregiver education on medications • Medication reconciliation (5) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee core membership • Women Veterans Health Committee reports to the Medical Executive Committee at least quarterly