The facility total loss rate reflects any loss, retirement, death, termination, voluntary ..... Beginning in March 2010, VHA performance on core hospital process of.
2010 VHA Facility Quality and Safety Report Department of Veterans Affairs Veterans Health Administration October 2010
1
Table of Contents Table of Contents
2
Executive Summary
5
Introduction
7
Part 1. VHA Facility Quality and Safety Data
9
Section 1: Infrastructure
9
Available In-House Services: Hospital Services Hospital Accreditation Status Hospital and Facility Services Section 2: Effective Care
9 10 11 12 13
Outpatient Care Composites Hospital Processes of Care Composites Risk Adjusted Disease Mortality 30 day Unadjusted Readmission Rates Surgical Quality Section 3: Equitable Care
13 18 20 20 21 22
Gender Age Satisfaction with Care by Race/Ethnicity Urban vs. Rural (See Tables 1.3 and 1.4) Table 1.4.g. How Well Doctors/Nurses Communicate Section 4: Safe Care
22 22 23 24 33 34
Health Care-Associated Infections Other Root Cause Analyses (RCAs) Section 5: Timely Care
34 35 36 37
Access to Care Section 6: Patient Centered Care
37 37
Section 7. Efficient Care
40
Ambulatory Care Sensitive Conditions Hospitalizations Results Conclusions
40 42 43
Part 2: Adverse Event and Close Call Reporting in the Veterans Health Administration FY06 to FY09 45 2
Introduction
45
Section 1: Overview and Event Types and Locations Associated with Root Cause Analyses Submitted FY06 to FY09 47 Primary Analysis and Categorization (PAC) Data by Setting and VISN 52 Section 2: Timeliness and Number of Root Cause Analyses Submitted FY06 to FY09 63 Section 3: RCAs Possessing “Strong Strings”
68
Section 4: Information on Reports That Were Not the Subject of Single Case RCAs 69 Part 3: VHA Facility Quality & Safety Data Tables Section 1: Infrastructure
74 74
Available In-House Services: Hospital Services Hospital Services (continued) Hospital Accreditation Status Hospital and Facility Services Hospital and Facility Services (continued) Section 2: Effective Care
74 80 88 97 103 112 121
Outpatient Care Composites and Hospital Processes of Care Composites Risk Adjusted Disease Mortality and Surgical Quality Section 3: Equitable Care
121 126 132
Gender Composites Age Composites Satisfaction by Race Section 4: Safe Care
132 137 143 148
Health Care-Associated Infections Other Root Cause Analyses (RCAs) Section 5: Timely Care
148 154 159 165
Access to Care Section 6: Patient Centered Care
165 171
Section 7. Efficient Care Ambulatory Care Sensitive Conditions Hospitalizations Part 4: Data Definitions
179 179 185
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Section 1: Infrastructure Available In-House Services Hospital Services Hospital Accreditation Status Hospital and Facility Services Section 2: Effective
185 185 186 187 188 190
Outpatient Care Composites 190 Hospital Processes of Care Composites 191 Risk Adjusted Disease Mortality - Data Source: VA Inpatient Evaluation Center (IPEC). 192 30 Day Unadjusted Readmission Rates 193 Surgical Quality 194 Section 3: Equitable 195 Gender: female, male Age, 9 o LDL-C screening. o LDL-C controlled to less than 100 mg/dL. o Patients receiving any retinal screening during the report period, or a documented refusal of a diabetic eye exam. o Patients who have received nephropathy screening. o Diabetic blood pressure
