Comprehensive Healthcare Inspection Program Review of the San Francisco VA Health Care System, California

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the San Francisco VA Health Care System. The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances 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. Apart from the Director, the executive leaders were relatively new to their positions. The OIG noted the Facility leaders’ efforts to address nursing challenges, engage employees, and continue efforts to improve employee satisfaction. Patients were generally satisfied with the care provided. Organizational leadership appeared to support patient safety and quality care. However, organizational risk factors, such as potential underreporting of adverse events and lack of an integrated and functional senior level QSV framework, may contribute to future issues of noncompliance and/or lapses in patient safety. The leaders should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics likely contributing to the current “3-Star” rating. The OIG noted findings in five of the clinical operations reviewed and issued 12 recommendations that are attributable to the Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) QSV • Physician Utilization Management Advisors’ documentation of decisions • Interdisciplinary review of utilization management data (2) Credentialing and Privileging • Focused Professional Practice Evaluation process (3) Environment of Care • Environment cleanliness • Protection of patient health information • Documentation of response time during panic alarm testing • Annual review of comprehensive emergency management plan (4) Medication Management: Controlled Substances Inspection Program • Annual physical security survey • Order verification • Monthly inspections (5) Long-term Care: Geriatric Evaluations • Program evaluation