Comprehensive Healthcare Inspection of the Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the Jonathan M. Wainwright Memorial VA Medical Center, 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 Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; and Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up. The facility’s executive leaders had worked together for one month, with three of the four positions permanently assigned during the OIG visit. Three of four executive leaders’ employee satisfaction scores were generally similar to or better than VHA averages. Patient experience questions showed one score above and one below VHA averages. Facility leaders were engaged with employees and patients and working to improve engagement and satisfaction. Leaders supported efforts to improve and maintain patient safety, quality care, and other positive outcomes. Leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to take actions to improve performance contributing to the facility’s SAIL “2-star” quality rating. No substantial organizational risk factors were identified. The OIG issued 17 recommendations for improvement: (1) Medical Staff Privileging • Professional practice evaluation processes (2) Environment of Care • Patient information protection • Environmental safety • Inspections and testing processes (3) Medication Management: Controlled Substances Inspections • One-day’s dispensing reconciliation • Hard copy prescription verification (4) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • MST training • Communication with leadership • MST initial evaluations (5) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee processes • Patient notification of abnormal results