Report Summary

Title: Clinical Assessment Program Review of the Southern Arizona VA Health Care System, Tucson, Arizona
Report Number: 16-00554-148
Issue Date: 3/13/2017
City/State: Tucson, AZ
Sierra Vista, AZ
Yuma, AZ
Casa Grande, AZ
Safford, AZ
Green Valley, AZ
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CAP Reviews
Release Type: Unrestricted
Summary: The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided at the Southern Arizona VA Health Care System. This included reviews of aspects of key clinical and administrative processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care; Medication Management; Coordination of Care; Diagnostic Care; Moderate Sedation; Community Nursing Home Oversight; and Management of Disruptive/Violent Behavior. OIG also provided crime awareness briefings to 74 employees. OIG identified system weaknesses in Quality, Safety, and Value Committee oversight; utilization management; environmental cleanliness; general safety; anticoagulation processes and competencies; transfer documentation; informed consent for moderate sedation procedures; community nursing home program oversight, annual reviews, and clinical visits; and management of disruptive/violent behavior training. As a result of the findings, OIG could not gain reasonable assurance that: (1) aggregate quality of care data is available, (2) utilization management data is reviewed, (3) medical waste stored for pick-up and chemicals stored in the hemodialysis unit are secured, (4) clinicians use laboratory tests to safely initiate anticoagulation therapy and have competency to manage anticoagulation therapy, (5) providers safely transfer patients from the facility, (6) providers notify patients of changes in the provider performing the moderate sedation procedure, (7) facility leaders monitor the Community Nursing Home Program and assure the safe care of program patients, (8) employees are trained to reduce and prevent disruptive behaviors, and (9) patients with identified learning barriers receive accommodations to ensure medication counseling is understood.
OIG made recommendations for improvement in the following seven areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management: Anticoagulation Therapy; (4) Coordination of Care: Inter-Facility Transfers; (5) Moderate Sedation; (6) Community Nursing Home Oversight; and (7) Management of Disruptive/Violent Behavior. OIG made a repeat recommendation in Medication Management.