Combined Assessment Program Review of the VA Eastern Kansas Health Care System, Topeka, Kansas

Report Information

Issue Date
Report Number
14-02064-252
VISN
State
Kansas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
18
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. This review focused on seven operational activities. The facility complied with selected standards in the following two activities (1) coordination of care and (2) community living center resident independence and dignity. The facility’s reported accomplishments were adding an onsite pharmaceutical dispensing script center and the Healthcare Field Analytics Program. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) environment of care, (3) medication management, (4) acute ischemic stroke care, and (5) magnetic resonance imaging safety.

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 actions from peer reviews are consistently completed and reported to the Peer Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Peer Review Committee consistently submit quarterly summary reports to the Medical Executive Committee.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group meet monthly and consistently document its review of National Surgical Office reports.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that data from electronic health record quality reviews are analyzed at least quarterly.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the quality control policy for scanning include how a scanned image is annotated to identify that it has been scanned.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Tissue and Transfusion Committee member from Anesthesia Service consistently attends meetings.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that damaged optical examination chairs in the eye clinics are repaired or removed from service.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
No. 9
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. 10
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. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility collect and report to VHA the percent of patients with stroke symptoms who had the stroke scale completed and the percent of patients screened for difficulty swallowing before oral intake.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that contrast reaction emergency drills are conducted in magnetic resonance imaging and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted 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 radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that appropriate signage and barriers be in place at the Leavenworth division to restrict access to magnetic resonance imaging Zone III.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Magnetic Resonance Imaging Safety Committee and the Patient Safety Manager evaluate the identified potential safety and security risks and take appropriate actions.