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 Puget Sound Health Care System (the Facility). 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 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 75 employees. The Facility’s leadership team is relatively new. With the exception of the Acting Assistant Director, the executive leaders have been working together as a team since October 2017. 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 OIG’s review of survey data suggested generally satisfied employees, opportunities appear to exist to improve outpatient experiences. The senior leadership team was knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance likely contributing to the two-star ranking. The OIG noted findings in two of the eight areas of clinical operations reviewed and issued five recommendations that are attributable to the Director, Chief of Staff, Deputy Director, and Assistant Director. The identified areas with deficiencies are: (1) Environment of Care • Environment of care rounds attendance • Medical equipment safety • Infection Prevention Committee’s discussion and documentation of on-going construction activities • Temperature monitoring in dry food storage areas (2) Medication Management: Controlled Substances Inspection Program • Reconciliation of controlled substances dispensing and return of stock
Seattle, WA
United States
