Comprehensive Healthcare Inspection Program Review of the VA Southern Nevada Healthcare System, North Las Vegas, Nevada

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 Southern Nevada Healthcare System. 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: Posttraumatic Stress Disorder; Long-term Care: Geriatric Evaluations; Women’s Health: Mammography; and High-risk Processes: Central Line-Associated Bloodstream Infections. The Facility had generally stable executive leaders who appeared actively engaged with employees. However, opportunities exist to improve patient experiences in the outpatient setting. The OIG reviewed accreditation agency findings, adverse events, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results and did not identify any substantial organizational risk factors. The leadership team was knowledgeable about selected SAIL metrics but should continue to take actions to improve performance of Quality of Care and Efficiency metrics likely contributing to the current “2-Star” rating. The OIG noted findings in four of the eight areas reviewed and issued eight recommendations attributable to the Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused Professional Practice Evaluation process (2) Environment of Care • Panic alarm testing (3) Medication Management: Controlled Substances Inspection Program • Annual physical security survey • Monthly inspections • Reconciliation process (4) Long-term Care: Geriatric Evaluations • Program evaluation