Federal Reports

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Amarillo VA Health Care System. The inspection covers leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. At the time of the review, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility’s executive leadership team appeared relatively stable and actively engaged with employees and patients. The leaders were also working to sustain employee and patient satisfaction which were above VHA averages and supported efforts to continually improve and maintain positive outcomes, patient safety, and quality care. Review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “4-star” and CLC “2-star” quality ratings, respectively. The OIG issued 19 recommendations for improvement in the following areas: (1) Quality, Safety, and Value • Interdisciplinary utilization management data review • Resuscitation episodes reviews (2) Medical Staff Privileging • Privileging process • Focused and ongoing professional evaluation processes (3) Environment of Care • Medication safety and infection prevention • Emergency power outlet testing (4) Mental Health • MST coordinator responsibilities • MST training (5) Geriatric Care • Patient/caregiver education on medications (6) Women’s Health • Women Veterans Health Committee core membership • Process to track cervical cancer screening data • Patient notification of abnormal results

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Cheyenne VA Medical Center. The inspection covers leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility’s executive leadership team appeared relatively stable; and efforts to continually improve and maintain positive outcomes, patient safety, and quality care were noted. Patients appeared generally satisfied with the leadership and care provided, but opportunities exist for the leaders to improve employee satisfaction. Review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to improve performance of measures that are likely contributing to the current SAIL “2-star” and CLC “3-star” quality ratings. The OIG issued 17 recommendations for improvement in the following areas: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data • Root cause analyses and resuscitation episode reviews (2) Medical Staff Privileging • Ongoing professional practice evaluation process (3) Environment of Care • Environmental cleanliness • Infection prevention • Emergency management (4) Mental Health • MST coordinator responsibilities • MST training (5) Geriatric Care • Patient/caregiver education and understanding of medications (6) Women’s Health • Women veterans health committee core membership (7) High-risk Processes • Labeling open medication vials in the emergency department with expiration dates

We identified actions that selected States took related to their oversight of opioid prescribing and their monitoring of opioid use. The selected States were Nebraska, Nevada, New Hampshire, Tennessee, Texas, Utah, Washington State, and West Virginia. This report summarizes and compares information provided by the eight States.