Comprehensive Healthcare Inspection of the Alaska VA Healthcare System, Anchorage, Alaska

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the Alaska VA Healthcare System,covering 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 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 executive leaders had been working together since August 2017. Employee satisfaction scores were generally higher than VHA averages. Leaders seemed actively engaged with patients and appeared to support efforts to improve and maintain patient safety and quality care. Review of accreditation findings, sentinel events, and patient safety indicator data did not identify any substantial organizational risk factors. Leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning metrics but should continue to act to improve performance of measures contributing to the Strategic Analytics for Improvement and Learning “3-star”quality rating. The OIG issued six recommendations for improvement: (1) Quality, Safety, and Value • Root cause analysis processes (2) Medication Management: Controlled Substances Inspections • Override report review (3) Mental Health: Military Sexual Trauma Follow-up and Staff Training • Military sexual trauma training (4) Geriatric Care: Antidepressant Use among the Elderly • Patient/caregiver medication education • Medication reconciliation (5) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership