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 VA North Texas Health Care System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Credentialing and Privileging; Quality, Safety, and Value; Environment of Care (EOC); Medication Management: Controlled Substances (CS) Inspection Program; Mental Health Care: Post-Traumatic 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 OIG also provided crime awareness briefings to 210 employees. The facility’s leadership team is relatively new. The OIG’s review of accreditation organization findings, sentinel events, disclosures, and Patient Safety Indicator data did not identify any substantial organizational risk factors. However, the OIG noted that the facility needed to establish a more accurate and reliable system for managing institutional disclosures. The OIG’s review of survey data suggested generally satisfied employees; however, opportunities exist to improve patient experiences. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics, and improvements demonstrated leadership’s continued commitment and efforts to improve care and performance of selected quality and efficiency metrics. The OIG noted findings in four of the clinical operations reviewed and issued six recommendations that are attributable to the Facility Director, Chief of Staff, and Nurse Executive. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused Professional Practice Evaluations include clearly delineated timeframes, criteria, and review of privilege-specific criteria • Ongoing Professional Practice Evaluations include the use and review of service- and practitioner-specific data (2) EOC • Availability of personal protective equipment (3) Medication Management: CS Inspection Program • Reconciliations of CS refills and returns to pharmacy (4) Women’s Health: Mammography Results and Follow-Up • Communication of results to patients
Washington, DC
United States
