Comprehensive Healthcare Inspection Program Review of the VA Palo Alto Health Care System, California

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Palo Alto Health Care System (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The Facility had generally stable executive leadership and active engagement with employees and patients to maintain high satisfaction scores. Organizational leadership supported patient safety, quality care, and other positive outcomes. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors. However, the OIG is concerned with the lack of Patient Safety Indicator data review and action. The senior leadership team should also continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics likely contributing to the “2-Star” rating. The OIG noted findings in four of the eight areas of clinical operations reviewed and issued eight recommendations that are attributable to the Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Documentation of Physician Utilization Management Advisor decisions • Reporting and documentation of patient incidents • Completion of annual Patient Safety Reports (2) Environment of Care • Attendance of Environment of Care rounds • Panic alarm testing at community based outpatient clinics (3) Medication Management: Controlled Substances Inspection Program • Controlled substances (CS) monthly inspections • CS reconciliation (4) Long-term Care: Geriatric Evaluations • Program oversight