Healthcare Inspection - Oversight Review of Quality of Care and Other Issues at the Grand Junction VA Medical Center, Grand Junction, Colorado

VA Office of Inspector General (OIG), Office of Healthcare Inspections conducted an oversight review to assess actions taken by Veterans Integrated Service Network (VISN) 19 and Grand Junction VA Medical Center (facility) leadership regarding the facility’s surgical program. Between May and September 2011, VHA surgery and quality management teams made onsite visits to the Grand Junction VA Medical Center. They identified concerns related to the surgery program and other issues. After the October CAP review and EAR survey, the OIG received allegations from facility staff. The allegations related to an increase in surgical infections and perforations, documentation, Emergency Department triage and surgical referral, resources, Quality Management program, scheduling, reusable medical equipment and safety. Because the VHA teams had previously reviewed most of the allegations, we conducted an oversight review to determine if the facility and VISN adequately addressed the concerns and allegations. We found that action plans had been developed to address these allegations and concerns. We recommended that the VISN Director continues to monitor facility action plans to ensure effective and complete follow up.