Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona

Report Information

Issue Date
Report Number
14-04220-363
VISN
State
Arizona
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
11
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 28 employees. This review focused on eight operational activities. The facility complied with selected standards in the following three activities: (1) medication management, (2) coordination of care, and (3) emergency airway management. The facility’s reported accomplishment was the development and implementation of a universal traveling veteran consult. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) environment of care, (3) magnetic resonance imaging safety, (4) acute ischemic stroke care, and (5) 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 the Surgical Work Group include the Chief of Staff as a member.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure employees receive training on chemical labeling/safety data sheets.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended 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 facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 5
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. 6
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. 7
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. 8
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. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians obtain cardiac markers, partial thromboplastin time, and an electrocardiogram while assessing patients presenting with stroke symptoms and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that medicine/telemetry unit employees have 12-lead electrocardiogram competency assessment and validation included in their competency checklists.