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

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Kansas City VA Medical Center and multiple outpatient clinics in Kansas and Missouri. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The executive leaders were permanently assigned. Employee satisfaction survey results revealed opportunities for the Associate Director for Patient Care Services to improve employee engagement and empowerment. Patients appeared generally satisfied with the care provided. Review of the facility’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. Executive leaders were generally knowledgeable within their scope of responsibilities contributing to specific poorly performing Strategic Analytics for Improvement and Learning quality measures. However, the OIG noted that only 6 of 29 VHA quality metrics showed high performance compared to other facilities, indicating multiple opportunities exist for improvement. The OIG issued 20 recommendations for improvement in seven areas: (1) Quality, Safety, and Value • Root cause analysis processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit review processes (3) Environment of Care • Medication storage • Clinic privacy (4) Medication Management • Behavior risk assessment • Urine drug testing • Informed consent • Follow-up after therapy initiation • Pain Management Committee processes (5) Mental Health • Suicide prevention training (6) Care Coordination • Life-Sustaining Treatment Decisions Committee processes (7) High-Risk Processes • Risk analysis • Airflow monitoring • Environmental safety • Equipment storage • Staff training