Community Based Outpatient Clinic Reviews at VA Western New York Healthcare System, Buffalo, NY

Report Information

Issue Date
Report Number
13-00026-352
VISN
State
New York
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 VA Western New York Healthcare System’s six Community Based Outpatient Clinics (CBOCs) during the week of August 12, 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 Lackawanna, NY, and Niagara Falls, NY, 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 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 required 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 required 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 managers ensure that clinicians document all required tetanus and pneumococcal vaccine administration elements and that compliance is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Executive Committee of the Medical Staff grants privileges consistent with the services provided at the Lackawanna and Niagara Falls CBOCs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that laboratory specimens are secured during transport from the Lackawanna and Niagara Falls CBOCs to the parent facility to prevent the disclosure of patients PII.