Comprehensive Healthcare Inspection Program Review of the Veterans Health Care System of the Ozarks, Fayetteville, Arkansas

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Veterans Health Care System of the Ozarks (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health Care: Posttraumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The OIG also provided crime awareness briefings to 125 employees. Although two of the Facility’s four executive leaders were in interim positions during the OIG’s on-site visit, the leaders had worked to support efforts related to patient safety, quality care, and other positive outcomes. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Although the leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to improve care and performance of selected Quality of Care and Access metrics that are likely contributing to the “4-Star” rating. The OIG noted findings in five of the eight areas of clinical operations reviewed and issued six recommendations that are attributable to the Facility Director, Chief of Staff, and Interim Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Interdisciplinary review of UM data (2) Credentialing and Privileging • Ongoing Professional Practice Evaluation process (3) Environment of Care • Environment of Care rounds participation (4) Medication Management: Controlled Substances Inspection Program • CS Coordinator position description • Controlled substances order verification (5) Women’s Health: Mammography Results and Follow-Up • Linkage of mammography results to radiology order