Comprehensive Healthcare Inspection of the Kansas City VA Medical Center, Missouri

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the Kansas City VA Medical Center, covering leadership, organizational risks, and key 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; and Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The executive leaders were permanently assigned. Selected survey scores related to employees’ satisfaction were generally similar to or better than VHA averages. However, opportunities exist for the associate director for Patient Care Services to improve employee satisfaction. The leaders appeared to support efforts to improve and maintain patient safety and quality care. The OIG’s review of the facility’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. The leaders were knowledgeable within their scope of responsibility about selected Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to take actions to improve performance contributing to the facility’s SAIL “2-star” quality rating. The OIG issued 14 recommendations: (1) Quality, Safety, and Value • Peer review of applicable deaths and suicides • Interdisciplinary review of utilization management data (2) Environment of Care • Safety, infection prevention, and emergency management processes • Locked inpatient mental health unit security (3) Controlled Substances Inspections • Controlled substances reconciliation (4) Military Sexual Trauma Follow-up and Staff Training • Military sexual trauma mandatory training (5) Geriatric Care • Patient/caregiver education on medications • Medication reconciliation (6) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership and reports to leadership (7) Emergency Department and Urgent Care Center • Backup call schedule for providers