Comprehensive Healthcare Inspection Program Review of the Grand Junction Veterans Health Care System, Grand Junction, Colorado

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 Grand Junction 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; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 104 employees. The facility has opportunities to maintain the stability of executive leadership with the appointment of a new facility director. OIG noted that current leaders have active engagement with employees and patients and the Daily Management System has improved the effectiveness and speed of communication. 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. The leadership team was knowledgeable about selected SAIL metrics and had taken actions to improve performance likely contributing to the current 4-star rating. OIG noted findings in four areas of clinical operations reviewed and issued nine recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Physician utilization management advisors’ documentation of decisions • Feedback about root cause analysis actions (2) Medication Management: Anticoagulation Therapy • Process for addressing anticoagulation-related calls outside of business hours • Quality assurance data reviews (3) Coordination of Care: Inter-Facility Transfers • Inter-facility transfer data reporting • Informed consent and communication of pertinent information to receiving facilities (4) Environment of Care • Attendance of Environment of Care rounds • Locked Mental Health Unit employee and interdisciplinary safety inspection team training