Comprehensive Healthcare Inspection of the El Paso VA Health Care System in Texas

Report Information

Issue Date
Report Number
22-00043-39
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
Medical Staff Privileging Credentialing
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the outpatient care provided at the El Paso VA Health Care System in Texas. This evaluation focused on four key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care The OIG issued three recommendations for improvement in two areas: 1. Quality, safety, and value • Patient safety events 2. Medical staff privileging • Focused and Ongoing Professional Practice Evaluations

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 System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager conducts a root cause analysis or includes the patient safety event in an aggregate review for all events assigned an actual or potential safety assessment code score of three.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff determines the reasons for noncompliance and ensures that practitioners with similar training and privileges complete Focused Professional Practice Evaluations of licensed independent practitioners.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Clinical Executive Board reviews and recommends licensed independent practitioners for reprivileging based on individual practitioners’ Ongoing Professional Practice Evaluations and documents its decisions in meeting minutes.