This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Northern Arizona VA Health Care System, covering leadership, 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; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility’s executive leaders were relatively new to their positions. Reviewing the facility’s accreditation findings, sentinel events, and disclosures, the OIG did not identify any substantial organizational risk factors. However, patient experience survey data revealed opportunities for improvement in the Patient-Centered Medical Home outpatient setting. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to take actions to improve performance of measures contributing to the facility’s SAIL “2-star” quality rating. The OIG issued 20 recommendations for improvement: (1) Quality, Safety, and Value • Utilization management processes • Root cause analyses actions • Analyses of resuscitation episodes (2) Medical Staff Privileging • Ongoing professional practice evaluation process (3) Environment of Care • Medication safety (4) Controlled Substances Inspections • Reconciliation for return of stock • Emergency drug cache inspection (5) Military Sexual Trauma Follow-up and Staff Training • MST Coordinator responsibilities • Providers’ training (6) Antidepressant Use among the Elderly • Patient/caregiver education • Medication reconciliation (7) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee requirements • Tracking cervical cancer screening data • Communicating abnormal results to patients (8) Emergency Departments and Urgent Care Center Operations • Backup call schedules for emergency department providers and social workers (9) Incidental Finding • Concentrated opioids storage safety
Prescott, AZ
United States
