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

摘要

The VA Office of Inspector General Office of Healthcare Inspections conducted an inspection to determine the validity of allegations regarding the management of emergency calls at the Primary Care Call Center (PCCC), VA San Diego Healthcare System (the system), San Diego, CA. We substantiated the allegations that PCCC agents did not follow established procedures for referring emergency calls for triage. We concluded that the PCCC had serious problems that put patients at risk. However, changes recommended by the Systems Redesign Committee and actions taken made significant improvements in PCCC timeliness in responding to calls and the abandonment rate. We substantiated that PCCC agents were inexperienced and lacked appropriate training. Failure to provide PCCC agents training on the basic competencies such as symptomatic and emergent call documentation and routing, and medical terminology put patients at risk. We substantiated the allegation that patient event reports were filed, but the Health Administrative Service did not evaluate the root causes of identified on-going problems. Managers were aware of this deficiency and initiated a Root Cause Analysis.