Comprehensive Healthcare Inspection of the West Texas VA Health Care System, Big Spring, Texas

Report Information

Issue Date
Report Number
19-00034-62
VISN
17
State
New Mexico
Texas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
13
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the West Texas VA Health Care System. The inspection covers leadership and organizational risks and key clinical and administrative 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; 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. The leadership team was relatively new, having worked together for four months as of the week of the OIG’s visit. Selected survey scores related to employee satisfaction and patient experiences demonstrated various opportunities for improvement. Review of the facility’s accreditation findings, sentinel events, disclosures, and safety indicators did not identify any substantial organizational risk factors. The leadership team should continue to take actions to sustain and improve performance measures contributing to the Strategic Analytics for Improvement and Learning and community living center “1-star” quality ratings. OIG issued 13 recommendations for improvement in the following areas: (1) Quality, Safety, and Value • Completion of required number of root case analyses • Patient safety annual report review • Resuscitative episode reviews (2) Controlled Substances Inspections • Monthly summary of findings and quarterly trends reports to the director • Quarterly quality management review of reports • Annual competency assessments • Verification of orders (3) Military Sexual Trauma Follow-up • Staff training (4) Geriatric Care: Antidepressant Use among Elderly • Patient/caregiver medication education (5) Women’s Health • Women Veterans Health Committee core membership (6) Emergency Department and Urgent Care Center Operations • Stop code for identification of Urgent Care Center patients • Contingency plan and back up call schedule • Emergency department integration software use

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the patient safety manager completes a minimum of eight root cause analyses each fiscal year and monitors for compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that facility leaders review a Patient Safety Annual Report at the end of the fiscal year and monitors the patient safety manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that the Code Blue/Rapid Response Team Committee reviews each resuscitative episode and monitors committee compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the controlled substance coordinator provides the monthly summary of findings and quarterly trends report to the director and monitors the controlled substance coordinator’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the Quality Executive Board reviews the controlled substance inspection program reports at least quarterly and monitors the quality manager’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the controlled substances coordinator performs and documents competency assessments of the controlled substance inspectors annually and monitors controlled substances coordinator’s compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain the controlled substances inspectors verify controlled substances orders for five random dispensing activities during monthly inspections and monitors the inspectors’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and monitors the clinicians’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the Women Veterans’ Advisory Committee is comprised of the required core members and monitors committee’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that urgent care center patients are assigned the appropriate stop codes to capture correct patient workload, productivity, and level of service and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that a written provider staffing contingency plan and backup call schedule are maintained for urgent care center providers and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the urgent care center implements the Emergency Department Integration Software tracking program and transmits data to the Emergency Medicine Management Tool and monitors compliance.