Comprehensive Healthcare Inspection of Veterans Integrated Service Network 17: VA Heart of Texas Health Care Network, Arlington, Texas

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the leadership performance and oversight by the Veterans Integrated Service Network (VISN) 17: VA Heart of Texas Health Care 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 Privileging; Environment of Care; and Medication Management: Controlled Substances Inspections. The OIG conducted this unannounced visit while concurrent inspections of the following Texas VISN 17 facilities were also performed: El Paso VA Health Care System (HCS); VA Texas Valley Coastal Bend HCS, Harlingen; and West Texas VA HCS, Big Spring. The VISN 17 leaders had worked together for over two years. Selected survey scores related to employee satisfaction and attitudes toward the workplace were generally above VHA averages, except for the Chief Medical Officer who appears to have opportunities for improvement. The leaders appeared to support efforts to improve patient safety, quality care, and other positive outcomes; however, patient experience results identified various improvement opportunities for the VISN to support its facilities. Review of VISN access metrics and clinician vacancies did not identify any significant organizational risks. The leaders were knowledgeable within their scope of responsibility about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center metrics, but should continue to support facility actions to improve care provided throughout VISN 17. The OIG issued seven recommendations for improvement: (1) Quality, Safety, and Value • Quality, safety, and value committee meets quarterly; and analyzes and reviews aggregated data • Peer review data collected and analyzed (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (3) Environment of Care • VISN safety and network emergency management committee processes (4) Controlled Substances Inspections • Quarterly trend report reviews