Clinical Assessment Program Review of the VA Salt Lake City Health Care System, Salt Lake City, Utah

Report Information

Issue Date
Report Number
16-00572-179
VISN
State
Idaho
Nevada
Utah
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
20
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided at the VA Salt Lake City Health Care System. 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 95 employees. OIG identified certain system weaknesses in credentialing and privileging and utilization management; general safety and reusable medical equipment processes and training; anticoagulation program processes and employee competency assessment; collection, reporting, and monitoring of patient transfer data; point-of-care testing; moderate sedation practices; community nursing home oversight; and disruptive/violent behavior management processes and training. As a result of the findings, OIG could not gain reasonable assurance that: (1) the process for reviewing Ongoing Professional Practice Evaluation data is effective; (2) physician advisors provide input for utilization management decisions; (3) the environment of care is safe; (4) the facility has effective processes and training for reusable medical equipment reprocessing; (5) anticoagulation and patient transfer data are used to improve the quality of care; (6) clinicians have documented competency to manage anticoagulation patients; (7) clinicians appropriately manage critical point-of-care test values; (8) employees document required moderate sedation elements; (9) community nursing home program patients are monitored and receive safe care; and (10) disruptive/violent behavior incidents are effectively managed, and employees receive appropriate training. OIG made recommendations for improvement in all eight review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management: Anticoagulation Therapy; (4) Coordination of Care: Inter-Facility Transfers; (5) Diagnostic Care: Point-of-Care Testing; (6) Moderate Sedation; (7) Community Nursing Home Oversight; and (8) Management of Disruptive/Violent Behavior.

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 review Ongoing Professional Practice Evaluation data semi-annually 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 Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies, the specific deficiencies, corrective actions taken to address identified deficiencies, and resolutions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure attendance is documented for all fire drills.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure fire drills have documented critiques.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure eye protection equipment is readily available for employees.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure standard operating procedures for the colonoscopes and endoscopes for esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography are consistent with manufacturer instructions for use.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive training at orientation for the types of reusable medical equipment they reprocess.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility consistently review and report all quality assurance data measures for the anticoagulation management program quarterly and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments knowledge of standard terminology, pharmacology of anticoagulants, monitoring requirements, dose calculation, common side effects, nutrient interactions associated with anticoagulation therapy, and drug to drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility collect and report data on patient transfers out of the facility.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility monitor and evaluate patient transfers as part of the quality management program.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Chief of Pathology and Laboratory Medicine Service ensure the point-of-care testing procedure manual is readily available to employees.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Chief of Pathology and Laboratory Medicine Service ensure employees who perform point-of-care glucose testing comply with facility policy for managing critical glucose values.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers include history of previous adverse experience with sedation or anesthesia in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinical teams, including the providers performing the procedures, conduct and document timeouts using a checklist prior to moderate sedation procedures and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Patient Safety Manager and Patient Advocate consistently attend Disruptive Behavior Committee meetings.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior 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.