Comprehensive Healthcare Inspection Program Review of the West Texas VA Health Care System, Big Spring, Texas

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the outpatient settings of the West Texas VA 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; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; Mental Health Residential Rehabilitation Treatment Program; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 105 employees. The facility currently has stable executive leadership; however, facility leaders have the opportunity to instill trust and value in the organization by improving patient experience and the perceived instability of executive leadership. Additionally, mental health and primary care staffing vacancies may contribute to future lapses in patient safety unless leadership implements processes to attract and retain qualified staff. The OIG’s review of accreditation organization findings, sentinel events, disclosures, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Facility leaders should continue to take actions to improve care and performance, particularly Quality of Care and Efficiency metrics likely contributing to the current 1-star SAIL rating. OIG noted findings in four areas of clinical operations reviewed and issued 11 recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are: (1) Medication Management: Anticoagulation Therapy • Patient education • Laboratory testing prior to initiating warfarin (2) Coordination of Care: Inter-Facility Transfers • Transfer documentation • Communication with accepting facility (3) Mental Health Residential Rehabilitation Treatment Program • Monthly self-inspections • Weekly contraband inspections • Door Alarms (4) Post-Traumatic Stress Disorder Care • Suicide risk assessments • Referral for and completion of diagnostic evaluations • Resident supervision documentation