Comprehensive Healthcare Inspection of the Tomah VA Medical Center in Wisconsin

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 Tomah VA Medical Center and multiple outpatient clinics in Wisconsin. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on 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 consisted of the acting Medical Center Director, Chief of Staff, acting Associate Director for Patient Care Services (ADPCS), and acting Associate Director. Survey scores related to employees’ satisfaction with the medical center leaders were generally similar to or better than the VHA averages; however, opportunities exist for the ADPCS to decrease staff’s feelings of moral distress in the workplace. Patient experience survey data reflected higher care ratings than the VHA averages in the outpatient setting, while inpatient results appeared to highlight opportunities for improvement. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. The executive leadership team was generally knowledgeable within their scope of responsibility about selected VHA data used by the Strategic Analytic for Improvement and Learning models and should continue to take actions to sustain and improve performance. The OIG issued four recommendations for improvement in three areas: (1) Mental Health • Annual suicide prevention refresher training (2) Women’s Health • Community-based outpatient clinic women’s health primary care providers • Women Veterans Health Committee membership (3) High-Risk Processes • Annual risk analysis