Comprehensive Healthcare Inspection of the VA Pacific Islands Health Care System, Honolulu, Hawaii

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the VA Pacific Islands Health Care System, covering leadership, organizational risks, and key processes associated with promoting quality care. For this inspection, the areas of focus 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 leaders were all permanently assigned. The OIG noted that opportunities exist for the associate director for Patient Care Services to improve nursing staff satisfaction and attitudes. The leaders appeared to support efforts to improve and maintain patient safety, quality care, and other positive outcomes. The OIG’s review of the facility’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. The leaders were 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 facility’s SAIL and CLC “2-star” quality ratings. The OIG issued 12 recommendations for improvement: (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, infection prevention, and patient privacy processes at the parent facility • Environmental cleanliness and protection of patient information at the Leeward Oahu VA Clinic (4) Controlled Substances Inspections • Verification of controlled substances orders (5) Military Sexual Trauma Follow-up and Staff Training • Military sexual trauma mandatory training (6) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership • Cervical cancer screening data tracking • Communicating abnormal results to patients