Comprehensive Healthcare Inspection of the Phoenix VA Health Care System in Arizona

Report Information

Issue Date
Report Number
22-00051-136
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
Patient Safety
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
6
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Phoenix VA Health Care System, which includes the Carl T. Hayden VA Medical Center 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 four areas: 1. Leadership and organizational risks • Institutional disclosures 2. Quality, safety, and value • Peer review committee recommendations for improvement actions • Review of peer review committee’s summary analysis 3. Medical staff privileging • Professional practice evaluations 4. Environment of care • Inspections • 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)

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Protected Peer Review Committee recommends improvement actions for all Level 3 peer reviews.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board reviews the Protected Peer Review Committee’s summary analysis quarterly.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs establish service-specific criteria for professional practice evaluations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Executive Director determines the reasons for noncompliance and ensures staff conduct environment of care inspections in patient care areas at the required frequency.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Executive Director determines the reasons for noncompliance and ensures staff post signage to indicate areas that are subject to video recording.