Deficiencies in the Women Veterans Health Program and Other Quality Management Concerns at the North Texas VA Healthcare System

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate concerns related to deficiencies in the Women Veterans Health Program; Quality, Safety and Value (quality management) in patient safety and clinical events leading to resuscitation attempts; and leaders’ responses to recommendations from oversight bodies at the facility. The facility responded appropriately to oversight review recommendations. An insufficient number of designated women’s health primary care providers was assigned and trained to provide gender-specific comprehensive primary care for women veterans at the facility; the length of appointment times was not adjusted as required for unique gender-specific care. Additionally, the Women Veterans Program Manager was not fully engaged and contributed to a failure to identify resources needed for the provision of women veterans’ healthcare. A gynecologist and advanced practice registered nurse shared a licensed vocational nurse to serve as the required chaperone during examinations, impeding simultaneous examinations. Community Care served as a vital women veterans’ health resource; however, the facility did not have a standard operating procedure to track the Community Care results that were administratively closed or reported back to the requesting Veterans Health Administration (VHA) provider. Prolonged vacancies within quality management contributed to deficient performance measurement and evaluation processes. Leaders were not aware of all adverse events requiring potential institutional disclosure and corrective actions to prevent future adverse events were delayed. Facility clinical staff lacked training and an understanding of nationally identified guidelines for conducting patients’ goals of care conversations regarding life-sustaining treatments. Due to a lack of consistent processes, the resuscitation committee did not capture and review all resuscitation attempts nor take corrective actions to identify the causes surrounding these events, as required by VHA policy. The OIG made 18 recommendations related to staffing, appointment times, current and future resources, community care, and quality management processes.