Comprehensive Healthcare Inspection Program Review of the South Texas Veterans Health Care System, San Antonio, Texas

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the South Texas Veterans Health Care System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. OIG also provided crime awareness briefings to 105 employees. The facility had stable executive leadership with the exception of the vacancy for the Associate Director; however, it appears that the vacancy has not impacted the provision of quality care. Facility leaders were actively engaged with employees and patients and were working to improve satisfaction scores. Organizational leaders support patient safety, quality care, and other positive outcomes. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to improve performance of the Quality of Care and Efficiency metrics likely contributing to the facility’s current 3-star rating. OIG noted findings in two of the areas of clinical operations reviewed and issued three recommendations that are attributable to the Chief of Staff, Nurse Executive, and Assistant Director. The identified areas with deficiencies are: (1) Environment of Care • Safety and infection prevention on the cardiac intensive care unit at the parent facility • Locked mental health unit employee and Interdisciplinary Safety Inspection Team member training (2) Long-Term Care: Community Nursing Home Oversight • Clinical visits for patients residing in community nursing homes