Federal Reports

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the West Texas VA Health Care System. 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; 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 leadership team was relatively new, having worked together for four months as of the week of the OIG’s visit. Selected survey scores related to employee satisfaction and patient experiences demonstrated various opportunities for improvement. Review of the facility’s accreditation findings, sentinel events, disclosures, and safety indicators did not identify any substantial organizational risk factors. The leadership team should continue to take actions to sustain and improve performance measures contributing to the Strategic Analytics for Improvement and Learning and community living center “1-star” quality ratings. OIG issued 13 recommendations for improvement in the following areas: (1) Quality, Safety, and Value • Completion of required number of root case analyses • Patient safety annual report review • Resuscitative episode reviews (2) Controlled Substances Inspections • Monthly summary of findings and quarterly trends reports to the director • Quarterly quality management review of reports • Annual competency assessments • Verification of orders (3) Military Sexual Trauma Follow-up • Staff training (4) Geriatric Care: Antidepressant Use among Elderly • Patient/caregiver medication education (5) Women’s Health • Women Veterans Health Committee core membership (6) Emergency Department and Urgent Care Center Operations • Stop code for identification of Urgent Care Center patients • Contingency plan and back up call schedule • Emergency department integration software use