Report Summary

Title: Comprehensive Healthcare Inspection of the Central California VA Health Care System Fresno, California
Report Number: 19-00006-191 Download
Issue Date: 8/22/2019
City/State: Fresno, CA
Merced, CA
Oakhurst, CA
Tulare, CA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Central California VA Health Care System (the facility), which covers leadership, organizational risks, and key processes associated with promoting quality care. Focus areas were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations.

At the time of the OIG’s on-site visit, the facility’s executive leadership team appeared relatively stable with three positions permanently filled for over two years and one position vacant for approximately one month. For selected employee survey scores, the OIG noted that employees appeared generally satisfied. However, opportunities appeared to exist to improve inpatient and Patient-Centered Medical Home outpatient experiences. Review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. The leadership team was knowledgeable within their scope of responsibility about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to improve performance of measures contributing to the SAIL “2-star” and CLC “3-star” quality ratings.

The OIG issued 11 recommendations for improvement in the following areas:

(1) Quality, Safety, and Value

• Interdisciplinary review of utilization management data

(2) Medical Staff Privileging

• Focused and ongoing professional practice evaluation processes

(3) Environment of Care

• Medication safety

• Mental health unit panic alarm testing response time documentation

(4) Controlled Substances Inspections

• Inventory balance adjustment processes

(5) Military Sexual Trauma (MST) Follow-up and Staff Training

• Providers’ training

(6) Emergency Departments and Urgent Care Center Operations

• Backup call schedule