VA Office of Inspector General Report Released - Eastern Oklahoma VA Health Care System
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Eastern Oklahoma VA Health Care System


VA Office of Inspector General Report Released

July 11, 2017

During the week of May 16-20, 2016, the VA Office of Inspector General (OIG) conducted a healthcare inspection in response to Sen. James Inhofe’s request to evaluate a range of clinical, staffing, and administrative practices at the Eastern Oklahoma VA Health Care System (EOVAHCS) in Muskogee, OK. 

At Sen. Inhofe’s request, OIG coordinated this review with The Joint Commission (TJC).  The scope included extensive review of EOVAHCS data, actions, and practices in FY 2015 and quarters 1–3 of FY 2016.

OIG made 19 recommendations in the areas of staffing, quality and administrative practices.

They included a recommendation for EOVAHCS to fill key leadership positions that had been in flux in the past year, which contributed to inconsistent oversight and communication in some areas.

A recommendation was also made to establish workgroups to improve quality metrics.

Most of EOVAHCS’s Quality, Safety, and Value (QSV) programs had been functioning adequately; however, some improvements were needed in key areas, which are outlined in detail in the full report to Congress. 

Eight recommendations were made by OIG and these areas are being tracked by the QSV Committee until they are resolved, which was another recommendation.

OIG found that EOVAHCS had difficulty recruiting and retaining employees in some areas, so a recommendation was made to the EOVAHCS Director to continue recruitment and hiring efforts, but ensure alternate methods were in place to meet patient care needs. 

EOVAHCS is currently using hiring incentives, tele-medicine, and contracted services to meet patient care needs.

OIG recommended the VISN 19 Director conduct a follow-up site visit to ensure corrective actions had been effective and recommended that the EOVAHCS Director continue efforts to enhance call center timeliness. OIG also found that EOVAHCS had not consistently met timeliness goals for Veterans Choice and Non-VA Care Coordination. 

Several factors affected the system’s ability to ensure timely Non-VA care, including a changing demand for services, an inadequate number of trained staff to process consultation requests, and a limited number of community-based providers.

At the time of this review, system managers had already begun implementing VISN recommendations to address Veterans Choice and Non-VA Care Coordination.

OIG made three recommendations to address needed improvement in the areas of abnormal lab result notification and interventions, consultation completion timeliness, and mental health staffing.

In addition, OIG found the Emergency Department (ED) is meeting performance targets for timeliness in most measures, but attention is needed to ensure patients who do not require admission are discharged timely from the ED.

Lastly, a recommendation was made to ensure that EOVAHCS maintains a clean and safe health care environment in accordance with applicable requirements.

“I have reviewed the OIG’s findings and recommendations and concur with all of them,” said EOVAHCS Director Mark E. Morgan. “We have already implemented or completed 11 of the recommendations and are actively working to complete the last eight by the end of the year.”