Comprehensive Healthcare Inspection of the VA Southern Oregon Rehabilitation Center and Clinics, White City, Oregon

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the VA Southern Oregon Rehabilitation Center and Clinics, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas 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; and Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up. The facility’s leadership team appeared relatively new, having worked together for six weeks, as of the week of the OIG’s visit. Selected survey scores revealed opportunities for the associate director to improve employee satisfaction and provide a safe workplace environment where employees feel comfortable with bringing forth issues or ethical concerns. Opportunities also exist for leaders to improve patient satisfaction. Review of accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. The leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to act to improve performance of measures contributing to the SAIL “3-star” quality rating. The OIG issued five recommendations for improvement: (1) Quality, Safety, and Value • Root cause analysis processes (2) Medical Staff Privileging • Ongoing professional practice evaluation processes (3) Antidepressant Use among the Elderly • Patient/caregiver education and evaluation of understanding • Medication reconciliation (4) Abnormal Cervical Pathology Results Notification and Follow-up • Patient notification of abnormal results