All eligible VHA facilities and programs were accredited by The Joint Commission .... [Nebraska/W. Iowa HEALTH CARE SYSTEM], Lake City [N. Florida/ S.
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
