Report Summary

Title: Comprehensive Healthcare Inspection Program Review of the Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington
Report Number: 17-01746-116 Download
Issue Date: 3/1/2018
City/State: Walla Walla, WA
Richland, WA
Lewiston, ID
La Grande, OR
Yakima, WA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

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 Jonathan M. Wainwright Memorial VA Medical Center (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Medication Management: Anticoagulation Therapy; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; Long-Term Care: Community Nursing Home (CNH) Oversight; and Mental Health Residential Rehabilitation Treatment Program. The OIG also provided crime awareness briefings to 92 employees. Due to past leadership and organizational failures, the facility and its leaders are in a state of transition and face a challenging task of improving the organizational culture. The leaders spoke enthusiastically of ongoing efforts to rebuild workforce and patient trust and engagement, boost employee and patient satisfaction, achieve leadership stability, and improve organizational performance. These actions included actively engaging with and involving employees at all levels and developing an infrastructure with key personnel that will support and sustain organizational transformation.

The OIG noted findings in four areas of clinical operations reviewed and issued 10 recommendations that are attributable to the Facility Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are:

(1) QSV

• Senior-level committee for QSV functions

• Annual completion of required root cause analyses

(2) Medication Management: Anticoagulation Therapy

• Analysis and reporting of quality assurance data

• Patient education specific for newly prescribed anticoagulant medications

• Laboratory tests completion prior to initiating anticoagulant medications

• Staff competency assessments

(3) EOC

• Frequency of and participation in EOC rounds

(4) Long-Term Care: CNH Oversight

• Multi-disciplinary participation in Oversight Committee

• Cyclical clinical visits