Comprehensive Healthcare Inspection of the Oscar G. Johnson VA Medical Center, Iron Mountain, Michigan

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Oscar G. Johnson VA Medical Center. The inspection covers leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. At the time of the review, the areas of focus were Quality, Safety, and Value (QSV); Medical Staff Privileging (MSP); Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma (MST) 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: Urgent Care Center (UCC) Operations. The facility’s executive leadership team appeared relatively stable and seemed to be actively engaged with employees and patients. The leaders were also working to sustain employee and patient engagement and satisfaction which were above VHA averages and appeared to support efforts to continually improve and maintain positive outcomes, patient safety, and quality care. Review of the facility’s accreditation findings, sentinel events, disclosures, and Patient Safety Indicator data did not identify any substantial organizational risk factors. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “5-star” and CLC “3-star” quality ratings, respectively. The OIG issued nine recommendations for improvement in the following areas: (1) QSV • Peer review improvement actions • Interdisciplinary review of utilization management data (2) MSP • Focused professional practice evaluation for cause process (3) Mental Health • MST initial evaluations (4) Geriatric Care • Patient/caregiver education on medications • Medication reconciliation (5) Women’s Health • Women Veterans Health Committee core membership (6) High-Risk Processes • Urgent care center registered nurse staffing • Backup call provider schedule