Combined Assessment Program Review of the Providence VA Medical Center, Providence, Rhode Island

Report Information

Issue Date
Report Number
14-02066-266
VISN
State
Rhode Island
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 (OIG) conducted a review to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 13 employees. This review focused on six operational activities. The facility complied with selected standards in the following three activities: (1) medication management, (2) coordination of care, and (3) magnetic resonance imaging safety. The facility’s reported accomplishments were Compensation and Pension Systems redesign, accreditation by the Commission on Cancer, and Pathway to Excellence® designation by the American Nurses Credentialing Center. OIG made recommendations for improvement in the following three activities: (1) quality management, (2) environment of care, (3) acute ischemic stroke care.

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 completed actions from peer reviews are reported to the Peer Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Special Care Committee collects data that measures performance in responding to codes.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Service Staff Committee meet monthly.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Blood Usage Review Committee meets at least quarterly and that the blood/transfusions usage review process includes the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that when data analysis indicates problems or opportunities for improvement, actions are consistently identified, implemented, and followed to resolution in surgical performance improvement activities, electronic health record quality reviews, and blood/transfusion reviews.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all patient care areas and public restrooms are clean and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that procedures for terminal cleaning of patient rooms are followed and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that in patient care areas, damaged furniture is repaired or removed from service and damaged surfaces are repaired and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the pharmacy clean room for compounding sterile products be brought into compliance with United States Pharmacopeia 797> cleanliness, sterility, and monitoring standards.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all required members of the Environment of Care Committee consistently attend committee meetings, that the program be strengthened to ensure effective surveillance activities, and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that VA Police update the facility’s Security Management Plan annually and submit quarterly security reports to the Environment of Care Committee.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinician assessment of patients presenting with stroke symptoms includes facility required PTT and PT/INR tests and that compliance be monitored.