Comprehensive Healthcare Inspection Program Review of the VA San Diego Healthcare System

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 VA San Diego Healthcare 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 63 employees. The Facility has stable executive leadership. The OIG noted generally satisfied employees; however, opportunities exist to improve inpatient experiences. Organizational leaders supported patient safety, quality of care, and other positive outcomes. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors, but the executive leaders should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics likely contributing to the “3-Star” rating. The OIG noted findings in four of the eight areas of clinical operations reviewed and issued five recommendations that are attributable to the Facility Director, Chief of Staff, Associate Director of Patient Care Services, Associate Director, and Assistant Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Ongoing Professional Practice Evaluations (2) Environment of Care • Environment of care rounds attendance • Environmental cleanliness (3) Medication Management: Controlled Substances Inspection Program • Controlled substances reconciliation (4) High-Risk Processes: Central Line-Associated Bloodstream Infections • Staff education