Comprehensive Healthcare Inspection of the Cheyenne VA Medical Center in Wyoming

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 Cheyenne VA medical center. The inspection covered 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; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior. When the OIG conducted this inspection, the medical center’s leaders had worked as a team for approximately 14 months. Employee satisfaction survey results indicated that the Associate Director had opportunities to model servant leadership and improve staff’s perception of workplace respect and their ability to discuss concerns. The Associate Director for Patient Care Services had an opportunity to reduce staff’s feelings of moral distress. Patient experience survey results showed general satisfaction with the care provided. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. However, the Chief of Staff and Associate Director for Patient Care Services had opportunities to improve their understanding of selected Strategic Analytics for Improvement and Learning data, and all leaders should continue actions to improve and sustain quality and efficiency. The OIG issued seven recommendations for improvement in three areas: (1) Quality, Safety, and Value • Surgical work group meeting attendance (2) Care Coordination • Patient transfer monitoring and evaluation • Transfer form completion • Medical record transmission (3) High-Risk Processes • Disruptive behavior reporting and tracking • Disruptive Behavior Reporting System • Staff training