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Combined Assessment Program Review of the VA Boston Healthcare System, Boston, Massachusetts

Report Information

Issue Date
Report Number
15-00078-364
VISN
State
Massachusetts
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
16
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 93 employees. This review focused on eight operational activities. The facility complied with selected standards in the following two activities (1) magnetic resonance imaging safety and (2) emergency airway management. The facility’s reported accomplishments were the Allergy Team and the establishment of live Facebook® chat sessions. OIG made recommendations for improvement in the following six activities: (1) quality management, (2) environment of care, (3) medication management, (4) coordination of care, (5) acute ischemic stroke care, and (6) surgical complexity.

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 facility managers review privilege forms annually and document the review.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility develop a plan to complete the conversion from a six-part credentialing and privileging folder to a two-part privileging folder.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair damaged floors, ceilings, and walls in patient care areas.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all patient care areas are clean and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that all furnishings on the acute behavioral health unit comply with the standards of the VA Mental Health Environment of Care Checklist and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair damaged or worn furnishings in patient care areas or remove them from service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all designated employees receive initial automated dispensing machine training and competency assessment and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that oral syringes are available for oral liquid medication administration and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the stroke policy to require the stroke team to respond in person within 30 minutes of receiving a call and that facility managers fully implement the revised policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that A2 and 3N nurses have 12-lead electrocardiogram competency assessment and validation included in their competency checklists.