Report Summary

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Sioux Falls VA Health Care System, 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; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations.

At the time of the OIG’s review, three of four executive leaders were serving in an acting capacity. The facility leaders appeared actively engaged with employees and patients and were working to sustain and further improve employee and patient engagement and satisfaction. The leaders also appeared to support efforts to improve and maintain patient safety, quality care, and other positive outcomes. The OIG’s review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. However, opportunities appear to exist for the leaders to improve their knowledge about and to continue to take actions to sustain and improve selected performance of measures contributing to the Strategic Analytics for Improvement and Learning “4-star” and Community Living Center “1-star” quality ratings.

The OIG issued eight recommendations for improvement in the following areas:

(1) Quality, Safety, and Value

• Interdisciplinary review of utilization management data

(2) Medical Staff Privileging

• Specialty-specific criteria for focused professional practice evaluations

(3) Environment of Care

• Infection prevention

(4) Medication Management

• Verification of controlled substance orders substances

(5) Mental Health

• Military sexual trauma training

(6) Geriatric Care

• Patient/caregiver education on medications

(7) Women’s Health

• Women Veterans Health Committee core membership

(8) High-risk Processes

• Emergency department registered nurse staffing