Comprehensive Healthcare Inspection of the Montana VA Health Care System in Fort Harrison

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 Montana VA Health Care System. The inspection covered key clinical and administrative processes associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.The healthcare system had vacancies in two of the five key leadership positions, with the Quality Management Officer serving as acting Assistant Director and acting Associate Director of Patient Care Services. Survey results indicated opportunities to improve employee attitudes toward leaders, the workplace, and workgroup relationships. Patient experience survey results highlighted opportunities for improvement in outpatient settings. Review of the healthcare system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. The executive leaders were generally knowledgeable about select data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.The OIG issued eight recommendations for improvement in four areas:(1) Quality, Safety, and Value• Systems redesign and improvement program reporting structure• Surgical work group processes• Action item implementation and monitoring(2) Registered Nurse Credentialing• Primary source verification of registered nurses’ licenses(3) Mental Health• Suicide prevention training(4) High-Risk Processes• Disruptive behavior committee attendance• Disruptive behavior training