Healthcare Inspection – Evaluation of System-Wide Clinical, Supervisory, and Administrative Practices, Oklahoma City VA Health Care System, Oklahoma City, Oklahoma

Report Information

Issue Date
Report Number
16-02676-13
VISN
State
Oklahoma
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
24
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection in response to Senator James Inhofe’s request to evaluate clinical, supervisory, and administrative practices at the Oklahoma City VA Health Care System (System), Oklahoma City, OK. We also evaluated the System Director’s concerns and coordinated parts of this review with The Joint Commission. Our comprehensive review identified multiple program areas, processes, and operations needing improvement. The root cause for many of these issues was poor and unstable leadership at a number of levels, most notably in the Director position. Without strong and effective leadership, an inattentive and apathetic organizational culture evolved that allowed problems to arise and persist. It was only after new leadership was installed in May 2016 that the culture improved and necessary changes took place. We made 24 recommendations.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network Director review the former Chief of Surgery’s performance in relation to issues discussed in this report, and confer with appropriate VA offices to determine the need for administrative action, if any.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the System Director consult with the National Center for Organizational Development to facilitate organizational improvement following leadership changes and extensive inspections and investigations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure use of the correct methodology to determine the severity assessment code for all reported patient safety events.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure compliance with the National Center for Patient Safety’s guidelines on initiation and completion of Root Cause Analysis.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that peer reviews are appropriately completed and address all relevant aspects of care provided by the reviewed clinician.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure a process is in place to identify and review cases where institutional disclosure may be indicated, and complete as appropriate.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the System Director ensure that the Quality, Safety and Value committee minutes include evidence of robust data analysis and action tracking to address performance deficiencies, and monitor for compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure adherence to all Veterans Health Administration peer review committee requirements, and monitor for compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that professional practice evaluations include performance data to support provider privileges and are conducted in accordance with Veterans Health Administration and System policy.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director evaluate the current System policy and services provided by low volume/no volume providers to determine whether the System should continue to provide those services or seek community alternatives.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director require service chiefs to assure that all providers within their purview secure and maintain appropriate computer access to ensure quality and continuity of patient care.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure availability of functional equipment, adequate staffing, and enhanced access for personal identity verification card completion.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure compliance in monitoring of resident supervision documentation in accordance with Veterans Health Administration and System policies, and take appropriate action when deficiencies are identified.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director review letters of agreement between the University of Oklahoma’s surgical residency program and the System to ensure compliance with Accreditation Council for Graduate Medical Education requirements.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director continue efforts to recruit and hire for vacancies, and ensure that, until optimal staffing is attained, alternate methods are consistently available to meet patient care needs.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure timely completion of specialty care consults and monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director implement a process to conduct routine scheduling audits to monitor compliance and identify ongoing training opportunities for all schedulers.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director conduct an evaluation of the potential improper payments resulting from clinic cancellations, take appropriate corrective actions, and establish policies to mitigate improper payments related to clinic cancellations from occurring in the future.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director continue efforts to improve call center timeliness.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director continue efforts to improve timeliness of Care in the Community Program consult completion; enhance patient and community provider understanding of Veterans Choice and Non-VA Care Coordination options; and continue to promote communication and coordination with TriWest Healthcare Alliance to assure appropriate, timely care for patients.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure Patient Aligned Care Team clinicians follow Veteran Health Administration requirements for patient notification and follow-up of clinically relevant abnormal laboratory results and document the actions in the electronic health record.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director monitor consultation completion timeliness and identify process improvements for consults exceeding 30 days.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director continue Emergency Department workgroup efforts to improve the timeliness of care, decrease the frequency of diversion status, and enhance customer service in the Emergency Department.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that all patient care areas comply with environment of care requirements and that action plans specifically address deficient areas identified in this report.