An unannounced evaluation at the Topeka VA shows satisfaction with leadership and care, according to an Office of the Inspector General’s report released this month.

The review looked at leadership and organizational risks; quality, safety and value; medication management; environment of care; and long-term care at community nursing homes.

The OIG conducts evaluations every few years at VA facilities. The assessments include interviews and patient and employee surveys. The agency’s visit took place in May.

The inspection determined senior managers routinely reviewed data and providers effectively coordinated care during inter-facility transfers. It also noted a generally clean and safe environment and found executive leaders monitor patient safety through formal mechanisms. At the time the visit took place, Alexander Hallock was chief of staff, which is part of the executive leadership. Hallock now serves as the associate chief of staff for education, said Joseph Burks, spokesman for VA Eastern Kansas Health Care System.

Burks said the inspection was very positive.

“This inspection and its results provide leaders and staff of VA Eastern Kansas an opportunity to not only sustain the great work and shared success being accomplished in key areas, but also fine-tuning and improving upon the quality of care being provided,” Burks said.

According to the findings, between May 2014 and May 2017, there were three institutional disclosures of adverse events. Such incidents involve disclosures to patients or their representatives about care resulting in death or serious injury. There were no reported sentinel events, which involve serious patient safety incidents, or large-scale disclosures which concern multiple patients suffering an adverse event.

While no substantial organizational risk factors were identified, the report noted there were more than 350 vacancies throughout the VA Eastern Kansas system. The Topeka VA has struggled to fill open positions for years, at one point closing the emergency department because of a staffing shortage.

According to the OIG report, the number of outpatient visits increased by more than 12,500 from fiscal year 2015 to 2016 and its medical care budget also increased. However the number of unique employees during that time dropped by nearly 100.

The report found previous recommendations made in 2014 and 2016 had been addressed. Five new recommendations, with a March 2018 target date for implementing, were issued. They include:

• Clinical managers should consistently review Ongoing Professional Practice Evaluation data every six months

• Physician utilization management advisors need to document their decisions in the national database

• Clinicians should provide education to patients with newly prescribed anticoagulant medications

• The interdisciplinary safety inspection team needs to receive annual training on identifying environmental hazards

• Social workers and nurses should conduct clinical visits to community nursing homes in compliance with the frequency required by the Veterans Health Administration’s policy

“Knowing there are somewhere in the vicinity of 3,000 potential findings that could occur, our staff was very pleased with the results,” Burks said.