Comprehensive Healthcare Inspection Summary Report Fiscal Year 2018

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered by randomly selected Veterans Health Administration (VHA) facilities. The inspection covers key processes associated with promoting quality care, including Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Posttraumatic Stress Disorder; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The Office of Inspector General (OIG) noted that 85 percent of leaders were assigned permanently at the 51 VA facilities visited from October 2017 through September 2018. These facility leaders generally appeared engaged in supporting quality, felt supported by VISN leaders, were aware of improvement efforts for employee and patient satisfaction, and actively addressed Joint Commission and OIG recommendations for improvement. Sixteen of the surveyed facilities with a “1-” or “2-star” Strategic Analytics for Improvement and Learning (SAIL) star rating had significant opportunities for improvement, and facilities with higher SAIL star ratings had fewer OIG recommendations for improvement. The OIG issued 16 recommendations for improvement: (1) Quality, Safety, and Value • Implementation of peer review improvement actions • Physician utilization management advisors’ inpatient stay reviews • Interdisciplinary utilization management data reviews • Feedback for root cause analysis actions (2) Credentialing and Privileging • Reporting of focused professional practice evaluations (FPPEs) to an appropriate committee of the medical staff • Clearly delineated timeframes in FPPEs • Service-specific data in ongoing professional practice evaluations (OPPEs) • Specialty-specific elements in selected specialty providers’ OPPEs (3) Environment of Care • Environmental cleanliness • Panic alarms testing • Floor cushioning in mental health unit seclusion rooms • Emergency operations plan/processes (4) Controlled Substances Inspections • Correction of deficiencies from annual physical security surveys • One-day reconciliation of stock between pharmacy and dispensing areas • Monthly controlled substances inspections (5) Geriatric evaluation program oversight/evaluation