Combined Assessment Program Review of the VA Northern California Health Care System Sacramento, California

The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we provided fraud and integrity awareness training to 472 employees. The review covered eight operational activities and followed up on recommendations from the prior CAP review. The system complied with selected standards in the following two areas (1) patient satisfaction survey scores and (2) staffing. We highlighted positive achievements in implementing an emergency department (ED) display board, developing an operating room slider board, and developing evidence-based cancer patient management models. We made recommendations for improvements in the following activities: QM – Strengthen aspects related to data gathering, analysis, and the reporting process; documenting data analyses discussions; evaluating corrective actions taken; and monitoring the medication reconciliation process. Pharmacy Operations and Controlled Substances Inspections – Correct weaknesses related to program oversight, monthly inspections, and inspector competency assessments. Environment of Care – Address security and safety issues and implement corrective actions. ED and Urgent Care Center Operations – Comply with VHA and system policy and monitor patient transfers. Medication Management – Document pain medication effectiveness within the required timeframe. Coordination of Care –Document patient understanding of discharge instructions.