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Healthcare Inspection - Access and Quality of Care Concerns, Phoenix VA Health Care System, Phoenix, Arizona, and Delayed Test Result Notification, Minneapolis VA Health Care System, Minneapolis, Minnesota

Report Information

Issue Date
Report Number
15-03867-287
VISN
State
Arizona
Minnesota
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
10
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
At the request of Congressman Tim Walz, OIG inspected the Phoenix VA Health Care System (VAHCS), Phoenix, AZ for allegations of wait times in Emergency Department (ED), cleanliness, Allergy Clinic, VA Police Department, outpatient pharmacy services, and primary care provider (PCP) assignment. An additional allegation at the Minneapolis VAHCS in Minneapolis, MN involved test result notification. We substantiated the length of stay (LOS) patients experienced on a day in 2015 was the longest ED patients experienced from March 1, 2014, through March 31, 2015, and was likely caused by unforeseeable episode of increased demand. The Phoenix VAHCS’s ED median wait time (190 minutes) for the period reviewed did not exceed the Veterans Health Administration’s LOS threshold and was similar to three Phoenix Medicare-certified hospitals. We determined an effective mechanism was not in place to recognize episodic, increased demand to adjust processes. We substantiated examination areas separated by curtains created a risk for inadvertent protected health information disclosure and patients brought to the Radiology Department from the ED were not always supervised. We identified an opportunity for improvement regarding timeliness of prescription delivery for discharged ED patients. We substantiated some Phoenix VAHCS treatment and public areas were not clean. We determined Environmental Management Services’ understaffing was a contributing factor. We substantiated Allergy Clinic staff did not consistently dispose of oral temperature probe covers properly. We could not substantiate the allegation that a VA police officer mishandled a Veteran. We substantiated the Phoenix VAHCS pharmacy should have provided the patient a recommended medication or appropriate substitution. We substantiated the patient was not assigned a PCP at the Phoenix VAHCS; however, he was assigned a PCP at Minneapolis VAHCS. We substantiated Minneapolis VAHCS staff did not ensure the patient received magnetic resonance imaging results within 14 days, as required. We made ten recommendations.

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 Acting Veterans Integrated Service Network 18 Director assign a team to review the Phoenix VA Health Care System Emergency Department processes and develop a plan to improve Emergency Department access and flow during times of increased demand.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting Veterans Integrated Service Network 18 Director assign a team to review the Phoenix VA Health Care System Emergency Department processes and develop a plan to decrease the number of patients who leave the Emergency Department without being seen by a provider.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Phoenix VA Health Care System Director review current verbal communication practices in the Emergency Department and determine what steps are reasonable to safeguard patient information.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Phoenix VA Health Care System Director assess Emergency Department medication prescription delivery practices to identify potential opportunities to improve pharmacy services.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Phoenix VA Health Care System Director ensure all patients in the Radiology Department are supervised.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Phoenix VA Health Care System Director assess Environmental Management Services staffing needs and take appropriate actions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Phoenix VA Health Care System Director ensure environment of care concerns identified in this report are corrected and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Phoenix VA Health Care System Director ensure Allergy Clinic staff use standard precautions when disposing used thermometer covers and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Phoenix VA Health Care System Director ensure patients receive recommended preventive medications or are offered substitutions if the medication is not on the VA National Formulary.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Minneapolis VA Health Care System Director ensure that test results are communicated to patients as required.