Comprehensive Healthcare Inspection of Veterans Integrated Service Network 15: VA Heartland Network in Kansas City, Missouri

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by the Veterans Integrated Service Network (VISN) 15: VA Heartland Network, covering leadership and organizational risks and key processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The OIG conducted this unannounced visit during concurrent inspections of VISN 15 facilities. The VISN’s executive leadership team appeared stable with the Network Director, Deputy Network Director, Chief Medical Officer, and Human Resources Officer serving together for the past four years. The Quality Management Officer joined the team in June 2019. Selected survey scores related to employee satisfaction and patient experience were similar to or higher than VHA averages. The OIG’s review of access metrics and clinical vacancies did not identify any substantial organizational risks. The executive team seemed to support efforts to improve and maintain positive outcomes (such as conducting site visits to improve performance and quality care for high-risk veterans and providing training for mental health and community living center staff). The team was also knowledgeable about Strategic Analytics for Improvement and Learning metrics but should continue to take actions to sustain and improve performance. The OIG issued 10 recommendations for improvement in four areas: (1) Quality, Safety, and Value • Utilization management annual summary review (2) Medication Management • Pain Management Strategy implementation and progress report • Pain committee establishment (3) Women’s Health • Interdisciplinary strategic planning activities • Quarterly program updates • Annual site visits • Educational resource development • Access and satisfaction data analysis • Maternity care outcome data tracking (4) High-Risk Processes • Facility corrective action plans