Comprehensive Healthcare Inspection of the Robert J. Dole VA Medical Center in Wichita, Kansas

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 Robert J. Dole VA Medical Center and multiple outpatient clinics in Kansas. 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 executive leadership team had worked together since 2018. The Director had served in the role since 2016. Employee satisfaction scores revealed opportunities for the Associate Director for Patient Care Services to improve employee attitudes towards senior leaders. Patients appeared satisfied with their care and leaders appeared actively engaged. The OIG identified significant concerns regarding incident review processes and identifying sentinel events and/or institutional disclosures. Leaders were able to speak knowledgeably about performance actions and survey results. Leaders were also generally knowledgeable about Strategic Analytics for Improvement and Learning data. The OIG issued 26 recommendations for improvement in all eight areas: (1) Quality, Safety, and Value • Utilization management data review • Root cause analysis processes • Annual patient safety report (2) Medical Staff Privileging • Professional practice evaluations • Provider exit reviews (3) Environment of Care • Supply storage • Environmental cleanliness • Privacy (4) Medication Management • Behavior risk assessment • Informed consent • Patient follow-up (5) Mental Health • Patient follow-up • Suicide safety plans • Staff training (6) Care Coordination • Multidisciplinary committee (7) Women’s Health • Women Veterans Health Committee membership (8) High-Risk Processes • Annual risk analysis • Airflow and infection control • Endoscope storage