Report Summary

Title: Comprehensive Healthcare Inspection of the Boise VA Medical Center in Idaho
Report Number: 20-01256-179 Download
Issue Date: 7/12/2021
City/State: Boise, ID
Twin Falls, ID
Caldwell, ID
Hines, OR
Mountain Home, ID
Mountain Home, ID
Salmon, ID
Salmon, ID
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 Boise VA Medical Center and five outpatient clinics in Idaho and 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.

At the time of the OIG’s virtual review, the executive leaders had worked together for over three months. Employee survey results for selected leadership questions were similar to or better than the VHA average. Patient experience survey results were higher than VHA averages, and patients appeared satisfied with their care. The OIG’s review of accreditation findings, sentinel events, and large-scale disclosures did not identify any substantial organizational risk factors. During the institutional disclosures review, the OIG identified surgical complications in two patients that appeared to meet peer review criteria but were not reviewed. The executive leaders were generally knowledgeable, within their tenure and scope of responsibilities, about VHA data and/or medical center-level factors contributing to Strategic Analytics for Improvement and Learning measures.

The OIG issued 10 recommendations for improvement in six areas:

(1) Medical Staff Privileging

• Provider exit review forms

(2) Medication Management

• Pain management committee processes

(3) Mental Health

• Suicide prevention outreach activities

• Suicide prevention training

(4) Care Coordination

• Life-sustaining treatment decision progress notes

(5) Women’s Health

• Gynecologic care coverage

• Designated women’s health primary care providers

• Women veterans health committee meeting attendance

• Women veterans program manager duties

(6) High-Risk Processes

• Standard operating procedures