Comprehensive Healthcare Inspection of the New Mexico VA Health Care System in Albuquerque

Report Information

Issue Date
Closure Date
Report Number
22-00046-126
VISN
22
State
Colorado
New Mexico
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
7
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 inpatient and outpatient care provided at the New Mexico VA Health Care System, which includes the Raymond G. Murphy VA Medical Center (Albuquerque) and multiple outpatient clinics in Colorado and New Mexico. This evaluation focused on five key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care • Mental health (emergency department and urgent care center suicide prevention initiatives) The OIG issued seven recommendations for improvement in three areas: 1. Quality, safety, and value • Recommend, implement, and monitor improvement actions • Peer review processes • Patient safety events 2. Medical staff privileging • Focused and Ongoing Professional Practice Evaluation processes 3. Environment of care • Maintain, inspect, and test biomedical equipment • Environmental cleanliness

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)
Closure Date: 2/26/2025

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Executive Leadership Board recommends, implements, and monitors improvement actions.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2023
The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Protected Peer Review Committee recommends improvement actions for Level 3 peer reviews.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2024

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures staff either conduct an individual root cause analysis for all events receiving an actual or potential safety assessment code score of three or include the events in an aggregated review.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2024

The Chief of Staff determines the reasons for noncompliance and ensures providers with similar training and privileges complete licensed independent practitioners’ Focused Professional Practice Evaluations.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2024

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs recommend licensed independent practitioners’ continued privileges based on Ongoing Professional Practice Evaluation activities.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2023
The Assistant Director determines the additional reasons for noncompliance and ensures staff maintain, inspect, and test biomedical equipment according to the manufacturer’s recommendations.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2025

The Associate Director and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff remove supplies from shipping cartons and corrugated boxes prior to putting them in clean storage areas.