Community Based Outpatient Clinic Reviews at Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA

Report Information

Issue Date
Report Number
13-00026-196
VISN
State
Massachusetts
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
5
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General reviewed the Edith Nourse Rogers Memorial Veterans Hospital’s four Community Based Outpatient Clinics (CBOCs) during the week of March 11, 2013. 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 Gloucester, MA, CBOC for a site visit and evaluated credentialing and privileging, environment of care, and emergency management processes. OIG noted opportunities for improvement and made a total of five 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 a process is established to ensure that the ordering provider or surrogate is notified of normal cervical cancer screening results within the allotted 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 with normal cervical cancer screening results are notified of 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 the Acting Facility Director ensures that the WH Liaisons collaborate with the Women Veterans Program Manager.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that laboratory specimens are secured during transport from the CBOCs to the parent facility to prevent the disclosure of patients' PII.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that all identified EOC deficiencies and corrective actions be tracked and trended by the EOC Committee.