Comprehensive Healthcare Inspection of the Amarillo VA Health Care System, Texas

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Amarillo VA Health Care System. The inspection covers leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. At the time of the review, 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; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility’s executive leadership team appeared relatively stable and actively engaged with employees and patients. The leaders were also working to sustain employee and patient satisfaction which were above VHA averages and supported efforts to continually improve and maintain positive outcomes, patient safety, and quality care. Review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “4-star” and CLC “2-star” quality ratings, respectively. The OIG issued 19 recommendations for improvement in the following areas: (1) Quality, Safety, and Value • Interdisciplinary utilization management data review • Resuscitation episodes reviews (2) Medical Staff Privileging • Privileging process • Focused and ongoing professional evaluation processes (3) Environment of Care • Medication safety and infection prevention • Emergency power outlet testing (4) Mental Health • MST coordinator responsibilities • MST training (5) Geriatric Care • Patient/caregiver education on medications (6) Women’s Health • Women Veterans Health Committee core membership • Process to track cervical cancer screening data • Patient notification of abnormal results