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Community Based Outpatient Clinic Reviews at Battle Creek VA Medical Center, Battle Creek, MI, and Captain James A. Lovell Federal Health Care Center, North Chicago, IL

Report Information

Issue Date
Report Number
12-03853-172
VISN
State
Illinois
Michigan
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
15
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General reviewed the Battle Creek VA Medical Center’s four Community Based Outpatient Clinics (CBOCs) during the week of December 3, 2012, and the Captain James A. Lovell Federal Health Care Center’s three CBOCs during the week of December 10, 2012. The purpose of the review was to assess whether the CBOCs provide veterans with consistent and safe high-quality health care. The review covered the clinical care components of women’s health cervical cancer screening and tetanus and pneumococcal vaccinations. We also randomly selected the Grand Rapids and Lansing, MI CBOCs; and the Evanston and McHenry, IL CBOCs for site visits and evaluated credentialing and privileging, environment of care, and emergency management processes. OIG noted opportunities for improvement and made a total of 15 recommendations to the Veterans Integrated Service Network (VISN) and facility managers.

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 managers ensure that patients with cervical cancer screening results are notified of results within the defined timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that patients are notified of cervical cancer screening results within the defined timeframe and that notification is documented in the EHR.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that a process is established to ensure that the ordering provider or surrogate is notified of normal cervical cancer screening results within the allotted time frame and that notification is documented in the EHR.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure clinicians administer pneumococcal vaccinations when indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Medical Executive Committee grants privileges consistent with the services provided at the Grand Rapids and Lansing CBOCs.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Executive Committee of the Medical Staff grants privileges that are consistent with the services provided at the Evanston and McHenry CBOCs.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers improve restroom access for disabled veterans at the Lansing CBOC.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers maintain a clean and functioning environment of care at the Lansing CBOC.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers clearly identify the location of fire extinguishers with appropriate signage at the Lansing CBOC.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers implement a system to maintain auditory privacy during the check-in process at the Lansing CBOC.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff secure PII on laboratory specimens during transport from the Lansing CBOC to the parent facility.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff secure PII on laboratory specimens during transport from the Evanston and McHenry CBOCs to the parent facility.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the IT server closet at the McHenry CBOC is maintained according to IT safety and security standards.