Healthcare Inspection - Management of Emergency Calls Primary Care Call Center, VA San Diego Healthcare System, San Diego, California

OIG conducted an inspection to determine the validity of multiple allegations regarding the management of emergency calls at the Primary Care Call Center (PCCC), VA San Diego Healthcare System, San Diego, CA. OIG substantiated the allegations that PCCC agents were not following established procedures for referring emergency calls for triage, PCCC agents were inexperienced and lacked appropriate training, and managers did not evaluate the root causes of identified on-going problems. We concluded that the PCCC had serious problems that put patients at risk. OIG recommended that the System Director ensure that: (1) managers monitor PCCC agents’ compliance with procedures, and re-evaluate processes to ensure all emergency calls are routed appropriately, (2) PCCC agents receive initial training on required competencies and that competencies are confirmed annually thereafter, and (3) Root Cause Analyses in response to patient event reports are completed and appropriate action taken as needed. The VISN and System Directors concurred with OIG’s findings and recommendations and provided acceptable action plans.