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Comprehensive Healthcare Inspection of the Roseburg VA Health Care System in Oregon

Report Information

Issue Date
Report Number
20-01259-196
VISN
20
State
Oregon
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
13
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Roseburg VA Health Care System, which includes the Roseburg VA Medical Center and three 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. When the team conducted this inspection, the healthcare system’s leaders had worked together for 16 months, with the most tenured leader permanently assigned in 2016. Survey results revealed opportunities to improve staff feelings of “moral distress” in the workplace. Patients appeared generally satisfied, but there were opportunities to improve the experiences of women veterans. The OIG identified concerns with root cause analysis action implementation and outcomes measurement. Leaders were knowledgeable about employee satisfaction and patient experiences. However, they had opportunities to improve their knowledge of VHA data and/or system-level factors contributing to specific poorly performing Strategic Analytics for Improvement and Learning measures. The OIG issued 13 recommendations for improvement in six areas: (1) Quality, Safety, and Value • Root cause analyses (2) Medical Staff Privileging • Ongoing professional practice evaluations • Provider exit reviews (3) Mental Health • Staff training (4) Care Coordination • Goals of care conversations (5) Women’s Health • Designated women’s health providers • Women veterans health committee (6) High-Risk Processes • Standard operating procedures • Staff training • Monthly staff continuing education

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 System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager or designee includes all required review elements in root cause analyses.
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 ensures that service chiefs evaluate practitioners based on service-specific criteria.
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 ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines the reasons for noncompliance and makes certain the Executive Council of Medical Staff reviews and evaluates licensed independent practitioners’ reprivileging requests and documents the review in the meeting minutes.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director evaluates and determines reasons for noncompliance and makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from the healthcare system.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Suicide Prevention Coordinator provides in-person Operation S.A.V.E. training at new employee orientation.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director evaluates and determines the reasons for noncompliance and ensures providers complete and document goals of care conversations.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director evaluates and determines the reasons for noncompliance and ensures providers complete and document goals of care conversations within the required time frame.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System 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.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that standard operating procedures are reviewed at least every three years and updated when there is a change in process or manufacturer’s instructions for use.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines the reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director of Patient Care Services determines the reasons for noncompliance and ensures that all employees who reprocess reusable medical equipment receive monthly continuing education.