Comprehensive Healthcare Inspection of the VA Western Colorado Health Care System in Grand Junction

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Western Colorado Health Care System in Grand Junction. The inspection covered key clinical and administrative processes associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID -19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Examining the Management of Disruptive and Violent Behavior. When the OIG conducted the virtual review, the executive leadership team had worked together for three months. The acting Associate Director for Patient Care Services had covered the role since September 2020. Employee satisfaction survey results identified opportunities for the Associate Director for Patient Care Services to provide a safe culture at work. Patient experience survey scores generally reflected higher care ratings than the VHA average. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance. The OIG issued four recommendations for improvement in three areas: (1) Quality, Safety, and Value • Review of aggregated data • Implementation and monitoring of recommended improvement actions (2) Registered Nurse Credentialing • Primary source verification of registered nurses’ licenses (3) High-Risk Processes • Disruptive behavior committee meeting attendance