Comprehensive Healthcare Inspection of Veterans Integrated Service Network 19: VA Rocky Mountain Network in Glendale, Colorado

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 19: VA Rocky Mountain Network in Glendale, Colorado, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection focused on Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Mental Health: Suicide Prevention; Care Coordination: Inter-facility Transfers; and Women’s Health: Comprehensive Care. The VISN’s executive leadership team had worked together for nearly six months at the time of the OIG’s review. All members of the leadership team were permanently assigned, and two members had over 30 years of VA experience. Selected survey scores related to employees’ satisfaction with the VISN executive team leaders were generally higher than VHA averages. However, the Deputy Network Director had opportunities to improve employee perceptions of leadership. Patient experience survey scores were similar to VHA averages. The OIG’s review of access metrics and clinical vacancies did not identify any substantial organizational risk factors. The executive leaders seemed to support efforts to improve and maintain patient safety, quality care, and other positive outcomes. They were also knowledgeable within their scope of responsibilities about selected Strategic Analytics for Improvement and Learning metrics and should continue to take actions to sustain and improve performance. The OIG issued four recommendations for improvement in three areas: (1) Quality, Safety, and Value • Peer review summary data (2) Medical Staff Credentialing • Physician credential file review (3) Women’s Health • Quarterly program updates • Staff education gaps assessments