Comprehensive Healthcare Inspection of the VA Eastern Colorado Health Care System in Aurora

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 VA Eastern Colorado Health Care System. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.The system’s executive leadership team appeared stable and had worked together for over a year at the time of the OIG review. The system was recruiting for a new associate director position, and the Associate Director for Patient Care Services had been detailed to another role since March 2020. Employee survey data revealed opportunities for leaders to improve workplace satisfaction. Patients appeared satisfied with inpatient care, although the OIG noted opportunities to improve patient-centered medical home and specialty care. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures did not identify any substantial risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.The OIG issued seven recommendations for improvement in four areas:(1) Quality, Safety, and Value• Quality management committee participation• Surgical work group attendance(2) Mental Health• Suicide prevention training(3) Care Coordination• Inter-facility transfer policy• Patient transfer monitoring and evaluation• Medical record transmission(4) High-Risk Processes• Disruptive behavior training