Comprehensive Healthcare Inspection Program Review of the VA Eastern Kansas Health Care System, Topeka, Kansas

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Eastern Kansas Health Care System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. OIG also provided crime awareness briefings to 118 employees. The facility had generally stable executive leadership and active engagement with employees and patients as evidenced by high satisfaction scores. Organizational leaders support patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the facility through active stakeholder engagement). OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and SAIL results did not identify any substantial organizational risk factors. OIG noted findings in four of the six areas of clinical operations reviewed and issued five recommendations that are attributable to the Chief of Staff, Nurse Executive, and Assistant Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Review of Ongoing Professional Practice Evaluation data • Documentation of decisions by Physician Utilization Management Advisors (2) Medication Management: Anticoagulation Therapy • Education for patients with newly prescribed anticoagulant medications (3) Environment of Care • Locked Mental Health Unit Interdisciplinary Safety Inspection Team training (4) Long-Term Care: Community Nursing Home Oversight • Cyclical clinical visits