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

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 Oscar G. Johnson VA medical center and multiple outpatient clinics in Michigan and Wisconsin. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were 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 medical center’s executive leadership team included four positions, one was permanently filled less than four months and one (chief of staff) had been vacant for three months prior to the OIG visit. Employee satisfaction survey results for the Director and the ADPCS were markedly higher than VHA averages. Leaders supported efforts to improve and maintain patient safety, quality care, and other positive outcomes. The leadership team was extremely knowledgeable within their scope of responsibility about Strategic Analytics for Improvement and Learning data and should continue to act to sustain and improve performance. No substantial organizational risk factors were identified. The OIG issued 11 recommendations for improvement: (1) Medical Staff Privileging • Professional practice evaluation processes (2) Medication Management • Aberrant behavior risk assessment • Urine drug testing • Informed consent • Follow up after therapy initiation • Pain Committee activities (3) Women’s Health • Women Veterans Program Manager collateral duties (4) High-Risk Processes • Sterile Processing Services annual risk analysis • Staff training