Comprehensive Healthcare Inspection of the El Paso VA Health Care System, Texas

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the El Paso VA Health Care System, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused 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; and Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up. The facility’s leadership team had been working together for nine months, and the chief of staff and associate director were the newest members of the leadership team and were appointed in April and August 2018, respectively. Selected survey scores related to employee satisfaction with the facility’s leaders and patient experience survey data revealed opportunities to improve both employee and patient satisfaction. The organizational risk factors detailed in this report did not identify any substantial risk in quality of care. The leadership team was knowledgeable within their scope of responsibility about selected SAIL metrics but should continue to take actions to sustain and improve performance measures contributing to the SAIL “1-star.” The OIG issued seven recommendations for improvement in the following areas: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (2) Environment of Care • Annual inventory of resources and assets • Development and maintenance of an emergency operations plan (3) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (4) Geriatric Care: Antidepressant Use among the Elderly • Patient/caregiver education and understanding of medications (5) Women’s Health • Women Veterans Health Committee reports to leaders