Comprehensive Healthcare Inspection of the John J. Pershing VA Medical Center in Poplar Bluff, Missouri

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 John J. Pershing VA Medical Center, Poplar Bluff, Missouri. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; 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 executive team had been working together as a group for two months, although several team members had been in their positions for more than a year. Employee satisfaction survey results revealed opportunities for the Associate Director for Patient Care Services and Associate Director to decrease staff’s feelings of moral distress in the workplace. Patients appeared satisfied with their care. The OIG did not identify any substantial organizational risk factors. The leaders were knowledgeable about Strategic Analytics for Improvement and Learning data and should continue to take actions to sustain and improve performance. The OIG issued 17 recommendations for improvement across six areas: (1) Quality, Safety, and Value • Utilization management data review (2) Medical Staff Privileging • Focused professional practice evaluations • Provider exit review forms (3) Medication Management • Aberrant behavior risk assessments • Concurrent therapy with benzodiazepines • Urine drug testing • Informed consent • Follow-up after therapy initiation • Pain Management Sub-Committee activities (4) Mental Health • Follow-up visits • Suicide prevention training (5) Women’s Health • Women’s health primary care providers • Women Veterans Health Committee membership (6) High-Risk Processes • Standard operating procedures • Annual risk analysis • Staff competency assessments