Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas

Report Information

Issue Date
Report Number
12-03076-65
VISN
State
Texas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, OIG provided crime awareness briefings to 41 employees. This review focused on nine operational activities. The facility complied with selected standards in the following four activities: (1) continuity of care, (2) coordination of care, (3) environment of care, and (4) medication management. The facility’s reported accomplishments were the Patient Aligned Care Team Telehealth Pharmacy Services Program and the Nurse Triage Call Center. OIG made recommendations for improvement in the following five activities: (1) moderate sedation, (2) point-of-care testing, (3) colorectal cancer screening, (4) polytrauma, and (5) QM.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that providers re-evaluate patients immediately prior to sedation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that employees who perform glucose POCT have competency assessed at the required intervals.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility delineate all actions to be taken in response to critical results and that processes be strengthened to ensure that clinicians are notified of critical test results requiring follow-up.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results and document the actions taken and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that patients are notified of biopsy results within the required timeframe and that clinicians document notification.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the EHR Committee provides consistent oversight and coordination of EHR quality reviews and that EHR quality reviews are analyzed and trended.