Comprehensive Healthcare Inspection Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the VA Sierra Nevada Health Care System (the Facility) inpatient and outpatient settings. The review covered key clinical and administrative processes—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The OIG also provided crime awareness briefings to 169 employees. The OIG noted that despite working together as a team for less than one year, the Facility leaders communicated common goals and priorities and emphasized a transparent, inclusive leadership philosophy and practice. The OIG’s review of accreditation organization findings, sentinel events, disclosures, and Patient Safety Indicator data did not identify any substantial organizational risk. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning metrics, and improvements demonstrated the leaders’ continued commitment to advance beyond the “3-Star” rating. The OIG noted findings in five of the clinical operations reviewed and issued eight recommendations that are attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are: 1) Quality, Safety, and Value • Completion of required root cause analyses 2) Credentialing and Privileging • Utilization of service-specific data for Ongoing Professional Practice Evaluations 3) Environment of Care • Core members’ participation in environment of care rounds • Development and implementation of Hazard Analysis Critical Control Point Food Safety Plan • Implementation of quarterly Food Services inspections • Labeling of Food Items 4) Mental Health Care: Post-Traumatic Stress Disorder Care • Completion of Suicide Risk Assessments 5) High-Risk Processes: Central Line-Associated Bloodstream Infections • Training of Registered Nurses