Comprehensive Healthcare Inspection of the VA Eastern Kansas Health Care System in Topeka

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 Kansas Health Care System and multiple outpatient clinics in Kansas and Missouri. The inspection covers key clinical and administrative processes associated with promoting quality care. The 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 had been working together for two months, although the Director had served since 2012. Survey results revealed opportunities to improve employee satisfaction; however, patients appeared satisfied. Leaders were unable to speak knowledgeably about actions taken to maintain and improve performance and were minimally knowledgeable about Strategic Analytics for Improvement and Learning and community living center data. The OIG issued 39 recommendations for improvement in these seven areas: (1) Quality, Safety, and Value • Committee activities • Peer review processes • Utilization management processes • Root cause analysis processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit review processes (3) Environment of Care • General safety • Environmental safety and cleanliness • Medical supply storage and availability • Panic alarm testing • Privacy protection (4) Medication Management • Urine drug testing • Informed consent documentation • Follow-up after therapy initiation (5) Mental Health • Outreach activities • Suicide prevention care (6) Women’s Health • Community-based outpatient clinic-designated women’s health primary care providers • Women Veterans Health Committee processes (7) High-Risk Processes • Inventory file and standard operating procedures • Annual risk analysis • Airflow testing and equipment storage • Staff training