Comprehensive Healthcare Inspection of the Fargo VA Health Care System, North Dakota

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Fargo VA Health Care System. The inspection covers leadership and organizational risks and key clinical and administrative 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; 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 with all four positions permanently filled for longer than one year prior to the OIG’s visit. For selected employee and patient experience survey scores, the OIG noted that employees and patients were generally satisfied. The facility leaders appeared actively engaged and were working to sustain and further improve employee and patient engagement and satisfaction. The OIG’s review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. The leaders were 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 five recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data (2) Medical Staff Privileging • Use of ongoing professional practice evaluations for reprivileging decisions (3) Mental Health: Military Sexual Trauma Follow-up and Staff Training • Military sexual trauma training (4) High-risk Processes: Emergency Departments and Urgent Care Center Operations • Emergency department registered nurse staffing • Backup call schedule for emergency department providers