Breadcrumb

Combined Assessment Program Review of the Minneapolis VA Health Care System, Minneapolis, Minnesota

Report Information

Issue Date
Report Number
12-02599-03
VISN
State
Minnesota
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
8
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, OIG provided crime awareness briefings to 128 employees. This review focused on 10 operational activities. The facility complied with selected standards in the following six activities: (1) colorectal cancer screening, (2) coordination of care, (3) environment of care, (4) medication management, (5) mental health treatment continuity, and (6) QM. The facility’s reported accomplishments were a facility physician’s receipt of an award for outstanding achievement in clinical research and receipt of multiple awards for collaborating with other Veterans Integrated Service Network 23 teams to improve the coordination of cancer assessment and treatment. OIG made recommendations for improvement in the following four activities: (1) moderate sedation, (2) polytrauma, (3) point-of-care testing, and (4) nurse staffing.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that compliance be monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that minimum polytrauma staffing levels be maintained.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility monitor compliance with polytrauma training requirements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that Case Managers consistently communicate with the inpatient and/or their family at the required intervals.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that polytrauma patient care areas are clean and well maintained.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff document all required elements in response to critical values on a nursing progress note or the Nursing Critical Value Template note.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that nursing managers monitor the staffing methodology that was implemented in May 2012.