Comprehensive Healthcare Inspection Program Review of the New Mexico VA Health Care System, Albuquerque, New Mexico

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the New Mexico 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; High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. OIG provided crime awareness briefings to 33 employees. The facility has generally stable executive leadership to support patient safety, quality care, and other positive outcomes. However, the presence of organization risk factors, as evidenced by sentinel events, disclosures, and Patient Safety Indicator data, may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. Facility leaders should continue to take actions to improve performance of selected Strategic Analytics for Improvement and Learning metrics, particularly Quality of Care and Efficiency metrics. OIG noted findings in the six areas of clinical operations reviewed and issued 20 recommendations that are attributable to the Facility Director, Chief of Staff, Nurse Executive, Associate Director, and Assistant Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Ongoing Professional Practice Evaluation data review • Utilization management documentation (2) Medication Management: Anticoagulation Therapy • Quality assurance data review • Patient education • Required laboratory tests • Employee competency assessments (3) Coordination of Care: Inter-Facility Transfers • Transfer data analysis and reporting • Patient transfer documentation • Communication with accepting facility  (4) Environment of Care • Environment of care rounds frequency and attendance • General cleanliness • Outdated supplies • Physical security risk assessment • Mental health unit employee and inspection team training (5) High-Risk Processes: Moderate Sedation • Informed consent • Timeout participation and checklist (6) Long-Term Care: Community Nursing Home Oversight • Oversight committee representation • Monthly clinical visits