Comprehensive Healthcare Inspection of the St. Cloud VA Health Care System, Minnesota

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the St. Cloud VA Health Care System, covering leadership, organizational risks, and key processes associated with promoting quality care. For this inspection, areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma 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: Emergency Department and Urgent Care Center Operations. Most of the facility’s leadership team had been working together for nearly two years. The acting director, assigned in May 2019, was the newest member of the team; the associate director, the most tenured member, had been in the position since April 2012. Selected employee satisfaction and patient experience survey scores for the facility leaders were generally better than the VHA average. Facility leaders appeared to be actively engaged with patients and supportive of efforts to improve and sustain employee satisfaction. The organizational risk factors detailed in this report did not identify any substantial risk in quality of care. Facility leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning and community living center metrics but should continue to take actions to sustain the Strategic Analytics for Improvement and Learning “5-star rating” and improve performance contributing to the community living center “2-star” rating. The OIG issued four recommendations for improvement in the following areas: (1) Medical Staff Privileging • Ongoing professional practice evaluation processes (2) Mental Health • Military Sexual Trauma provider training (3) Geriatric Care • Patient/caregiver education and evaluation of understanding of newly prescribed medications (4) Women’s Health • Women Veterans Health Committee core membership