Clinical Assessment Program Review of the Harry S. Truman Memorial Veterans’ Hospital, Columbia, Missouri

Report Information

Issue Date
Report Number
16-00550-145
VISN
State
Missouri
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
13
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care provided at the Harry S. Truman Memorial Veterans’ Hospital. This included reviews of various aspects of key clinical and administrative processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care, Medication Management; Coordination of Care; Diagnostic Care; Moderate Sedation; Community Nursing Home Oversight; and Management of Disruptive/Violent Behavior. OIG provided crime awareness briefings to 155 employees. OIG identified certain system weaknesses in peer review and utilization management processes; environmental cleanliness; anticoagulation policies and processes; employee point-of-care testing competencies; documentation of actions for clinically significant point-of-care testing results; processes, procedures, and training related to the management of disruptive/violent behavior; and screening of clinical issues after codes. As a result of the findings, OIG could not be confident that: (1) the Peer Review Committee effectively tracks individual improvement action outcomes, (2) physician advisors provide input for utilization management decisions, (3) Cardiopulmonary Resuscitation Committee reviews assist with planning interventions, (4) patient nourishment areas are clean, (5) anticoagulation patients are able to contact employees with safety concerns, (6) employees use quality assurance data to improve anticoagulation patient care, (7) clinicians obtain all required laboratory tests before initiating anticoagulant medications and effectively monitor patients receiving anticoagulation therapy, (8) the facility maintains competencies for employees who perform point-of-care glucometer testing, (9) clinicians take action for clinically significant test results, and (10) the facility effectively manages disruptive/violent behaviors. OIG made recommendations for improvement in the following five review areas: (1) Quality, Safety, and Value; (2) Environment of Care, (3) Medication Management: Anticoagulation Therapy, (4) Diagnostic Care: Point-of-Care Testing, and (5) Management of Disruptive/Violent Behavior. OIG made a repeat recommendation in Quality Management.

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 clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure ice machines and refrigerators in patient nourishment kitchens are clean and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility review designated quality assurance data for the anticoagulation management program quarterly and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications and obtain required laboratory tests during warfarin treatment at the frequency required by local policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the laboratorydirector ensure employees who perform glucose testing at the point of care have annual competencies for glucometers and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians take anddocument all actions required by the facility in response to test results and that clinical managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facilityimplement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that VA Police officer,Patient Safety Manager, and Patient Advocate attendance is consistently documented at Disruptive Behavior Committee meetings.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility includeand test slow scan/closed circuit televisions, computer-based panic alarm systems, and electronic personal panic alarms in accordance with the local physical security assessment.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managersensure all employees receive Level 1 training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Cardiopulmonary Resuscitation Committee code reviews include screening for clinical issues prior to code that may have contributed to the occurrence of the code.