Comprehensive Healthcare Inspection of the VA St. Louis Health Care System in Missouri

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 St. Louis Health Care System and multiple outpatient clinics in Illinois and Missouri. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were 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 worked together for over two years. Survey results indicated that employees were generally satisfied. However, patient survey results were often lower than the corresponding VHA averages, indicating multiple opportunities for system leaders to improve satisfaction. The OIG identified the lack of a permanent pain director as an area of vulnerability for the healthcare system. Executive leaders were able to speak knowledgeably about performance improvement actions taken during the previous 12 months, employee satisfaction, and patient experiences. The OIG issued 20 recommendations for improvement in seven areas: (1) Quality, Safety, and Value • Improvement action implementation and monitoring • Utilization management processes • Root cause analysis processes (2) Medical Staff Privileging • Professional practice evaluation processes • Provider exit review forms (3) Environment of Care • Geriatric mental health unit safety (4) Medication Management • Behavior risk assessment • Urine drug testing • Informed consent • Patient follow-up after therapy initiation • Pain Committee activities (5) Mental Health • Community outreach activities • Patient follow-up visits • Staff training (6) Women’s Health • Women Veterans Health Committee membership and activities (7) High-Risk Processes • Bioburden testing • Staff training