Report Summary

Title: Comprehensive Healthcare Inspection of the VA Portland Health Care System in Oregon
Report Number: 20-01257-180 Download
Issue Date: 7/13/2021
City/State: Bend, OR
Salem, OR
Warrenton, OR
Lincoln City, OR
Fairview, OR
Hillsboro, OR
West Linn, OR
Newport, OR
Newport, OR
Portland, OR
The Dalles, OR
The Dalles, OR
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

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 Portland Health Care System and multiple outpatient clinics in Oregon. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Privileging; 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 healthcare system executive leadership team appeared stable, with all positions permanently assigned. Employee survey items revealed opportunities to improve satisfaction and staff feelings of moral distress at work. Patients appeared satisfied with their inpatient and specialty care experiences, but leaders have opportunities to improve the patient-centered medical home experience. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify substantial organizational risk factors. However, the OIG noted concerns with the healthcare system’s identification of sentinel events. Leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.

The OIG issued 17 recommendations for improvement in seven areas:

(1) Quality, Safety, and Value

• Improvement action implementation and monitoring

• Root cause analyses

(2) Medical Staff Privileging

• Provider exit review forms

(3) Medication Management

• Aberrant behavior risk assessments

• Urine drug testing

• Informed consent

• Patient follow-up

(4) Mental Health

• Patient follow-up

• Suicide prevention training

(5) Care Coordination

• Life-sustaining treatment decision notes

(6) Women’s Health

• Women veterans health committee reporting and membership

(7) High-Risk Processes

• Standard operating procedures

• Storage area humidity levels

• Staff training