Comprehensive Healthcare Inspection Program Review of the Central Texas Veterans Health Care System, Temple, Texas

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Central Texas Veterans Health Care System. The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances (CS) Inspection Program; Mental Health: Posttraumatic Stress Disorder Care; Long-term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-up; and High-risk Processes: Central Line-associated Bloodstream Infections. The Facility had relatively stable executive leadership and active engagement with employees as evidenced by satisfaction scores. However, opportunities exist to improve outpatient experiences. Additionally, the OIG identified the presence of organizational risk factors with Patient Safety Indicator data and delays in patients receiving sleep apnea equipment, which may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. The OIG noted findings in five of the clinical operations reviewed and issued 18 recommendations that are attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, Associate Director, Assistant Director–Austin, and Assistant Director–Waco. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (2) Environment of Care • Personal protective equipment accessibility • Environmental cleanliness • Medical equipment availability • Panic alarm testing and follow-up • Annual Emergency Operations Plan reviews (3) Medication Management: CS Inspection Program • Monthly and quarterly reports • CS inspectors’ appointments • Monthly area inspections • Verification of drugs held for destruction and hard copy prescriptions • Prescription pad accountability (4) Women’s Health: Mammography Results and Follow-up • Communication of results to patients (5) High-risk Processes: Central Line-associated Bloodstream Infections • Staff education