Comprehensive Healthcare Inspection of the Northern Arizona VA Health Care System in Prescott

Report Information

Issue Date
Closure Date
Report Number
22-00052-121
VISN
22
State
Arizona
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
Major Management Challenges
Healthcare Services
Recommendations
6
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 settings of the Northern Arizona VA Health Care System, which includes the Bob Stump VA Medical Center in Prescott and multiple outpatient clinics in Arizona. 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 six recommendations for improvement in two areas: 1. Medical staff privileging • Focused and Ongoing Professional Practice Evaluation processes 2. Environment of care • Damaged or compromised sterile supplies • Safe and clean environment and clinical areas in good repair • Notices in areas subject to photography or video recording

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: 5/3/2024

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define Focused Professional Practice Evaluation criteria in advance using objective criteria accepted by the licensed independent practitioner.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/8/2024

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs establish service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2023

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs base determinations to continue current privileges on Ongoing Professional Practice Evaluation activities.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/3/2024

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff remove sterile supplies from storage when the packaging is damaged or compromised.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2023
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff keep clinical areas in good repair and maintain a safe and clean environment throughout the healthcare system.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2023

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff post notices in areas that are subject to photography or video recording.