Clinical Assessment Program Review of the El Paso VA Health Care System, El Paso, Texas

The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided in the inpatient and outpatient settings of the El Paso VA Health Care System. This included reviews of various aspects of key clinical and administrative processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care; Medication Management; Diagnostic Care; Community Nursing Home Oversight; Management of Disruptive/Violent Behavior; and Post-Traumatic Stress Disorder Care. OIG also followed up on recommendations from the previous Combined Assessment Program and Community Based Outpatient Clinic and Primary Care Clinic reviews and provided crime awareness briefings to 291 employees. OIG identified certain system weaknesses in credentialing and privileging, patient safety, and root cause analysis; anticoagulation policies and processes; Community Nursing Home Oversight Committee membership; disruptive/violent behavior management training; and suicide risk assessments for patients who screened positive for post-traumatic stress disorder. As a result of the findings, OIG could not gain reasonable assurance that: (1) The facility has an effective process for reviewing Ongoing Professional Practice Evaluation data; (2) The Patient Safety Manager enters all reported patient incidents into the required database; (3) The facility takes actions in root cause analyses when data analyses indicate problems or opportunities for improvement; (4) The facility has comprehensive policies and processes for anticoagulation management; (5) The Community Nursing Home Oversight Committee includes all required members; (6) The facility ensures employees receive training to reduce and prevent disruptive behaviors; (7) Patients with positive post-traumatic stress disorder screens receive suicide risk assessments. OIG made recommendations for improvement in the following five review areas: (1) Quality, Safety, and Value; (2) Medication Management: Anticoagulation Therapy; (3) Community Nursing Home Oversight; (4) Management of Disruptive/Violent Behavior; and (5) Post-Traumatic Stress Disorder Care.