Comprehensive Healthcare Inspection of the Boise VA Medical Center in Idaho

Report Information

Issue Date
Report Number
20-01256-179
VISN
20
State
Idaho
Oregon
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Major Management Challenges
Healthcare Services
Recommendations
10
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
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

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain a licensed healthcare professional’s first- or second-line supervisor completes provider exit review forms within seven business days of professionals’ departure from the medical center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Pain Management Committee monitors the quality of pain assessment and effectiveness of pain management interventions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator conducts at least five suicide prevention outreach activities per month.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that all staff complete annual suicide prevention refresher training. 
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners complete life-sustaining treatment decision progress notes.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that processes and procedures are in place for 24 hours a day, 7 days per week Emergency Department and medical center call coverage for gynecologic care.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage when there is only one designated provider.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff complete competency assessments that align with medical center standard operating procedures prior to reprocessing reusable medical equipment.