The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the VA Northern California Health Care System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home (CNH) Oversight. OIG also provided crime awareness briefings to 404 employees. The facility has generally stable executive leadership to support patient safety, quality care, and other positive outcomes; however, leaders should continue to take actions to improve outpatient satisfaction scores. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to improve performance of the Quality of Care and Efficiency metrics likely contributing to the current 2-star SAIL rating. OIG noted findings in the six areas of clinical operations reviewed and issued 13 recommendations that are attributable to the Chief of Staff and Associate Directors. The identified areas with deficiencies are: (1) QSV • Peer review process • Review of Ongoing Professional Practice Evaluation data (2) Medication Management: Anticoagulation Therapy • Anticoagulation management policy • Laboratory testing • Employee competency assessments (3) Coordination of Care: Inter-Facility Transfers • Patient transfer documentation (4) EOC • EOC rounds attendance • Security surveillance television system testing • Locked mental health unit employee and Interdisciplinary Safety Inspection Team training (5) High-Risk Processes: Moderate Sedation • Assessments of previous history/experience with sedation • Timeout checklist (6) Long-Term Care: CNH Oversight • Annual reviews • Monthly clinical visits
Mather, CA
United States
