Report Summary

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Phoenix VA 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; 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 156 employees.

Upon review of selected employee and patient survey results, the OIG noted generally satisfied employees while Facility leaders face a challenging task of rebuilding patient and public trust while improving organizational performance.

The senior leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning metrics and acknowledged that ongoing efforts, commitment, and actions are critical to improve care and performance of metrics likely contributing to the Facility’s “1-Star rating.” The OIG did not identify any substantial organizational risk factors; however, the OIG is concerned with the number of in-hospital complications and adverse events following surgeries and procedures.

The OIG issued 13 recommendations in five of the eight areas of clinical operations reviewed. The identified areas with deficiencies are:

(1) Quality, Safety, and Value

• Physician Utilization Management Advisors’ documentation of decisions

• Documentation of patient incidents in WebSPOT database

(2) Environment of Care

• Attendance of environment of care rounds

• Accessibility of personal protective equipment

• Cleanliness of patient care areas

• Environmental safety, stored food labeling, and temperature monitoring in Nutrition and Food Services

(3) Medication Management: Controlled Substances Inspection Program

• Monthly inspections

• Patterns of inspections

• Reconciliation of returns to pharmacy stock

(4) Post-Traumatic Stress Disorder Care

• Offer of further diagnostic evaluation

(5) Long-Term Care: Geriatric Evaluations

• Medical evaluation