Clinical Assessment Program Review of the White River Junction VA Medical Center, White River Junction, Vermont

Report Information

Issue Date
Report Number
16-00556-244
VISN
State
New Hampshire
Vermont
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
24
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 in the inpatient and outpatient settings of the White River Junction VA Medical Center. 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 also provided crime awareness briefings to 154 employees. OIG identified certain system weaknesses in the quality, safety, and value program; anticoagulation policies and processes; transfer documentation; moderate sedation care; community nursing home oversight; and management of disruptive and violent behavior. As a result of the findings, OIG could not gain reasonable assurance that: 1. Facility leadership is involved in high-level oversight and decision-making by the Quality Management Board. 2. Clinical managers reviewed Ongoing Professional Practice Evaluation data to monitor trends in practice and patient outcomes. 3. The facility maintains effective oversight of utilization management processes. 4. The facility prioritizes patient safety improvement by conducting root cause analyses as required. 5. Clinical employees and leadership provide safe anticoagulation care. 6. Clinicians provide informed consent and communicate important information to other health care team members through the electronic health record when they transfer patients from the facility. 7. Providers and other clinical employees provide safe moderate sedation care. 8. The facility monitors the community nursing home program and assures the effective oversight of care of patients in these settings. 9. The facility has processes and procedures in place to prevent, reduce, and manage disruptive/violent behavior. OIG made recommendations for improvement in the following six review areas: (1) Quality, Safety, and Value; (2) Medication Management: Anticoagulation Therapy; (3) Coordination of Care: Inter-Facility Transfers; (4) Moderate Sedation; (5) Community Nursing Home Oversight; and (6) 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 the Quality Management Board is chaired or co-chaired by the Facility Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Quality Management Board routinely review aggregated data.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers ensure completion of at least 75 percent of all utilization management reviews and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers ensure an interdisciplinary group reviews utilization management data and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Patient Safety Manager ensures completion of eight root cause analyses each fiscal year and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility collect quality assurance data for the anticoagulation management program, that the Medication Use and Evaluation Committee annually review the data, and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure anticoagulation clinicians consistently obtain all required laboratory tests prior to initiating warfarin treatment.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for patients transferred out of the facility, providers consistently include date of transfer and patient or surrogate informed consent in transfer documentation and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for inter-facility transfers, facility managers ensure acceptable designees document staff/attending physician approval as evidenced by the presence of the approving staff/attending physician countersignature and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers include all the required elements in the history and physical and the pre-sedation assessment and that clinical managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinical employees document post-procedure assessments of patients' pain levels and that clinical managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinical employees discharge moderate sedation outpatients in the company of a responsible adult and that clinical managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinical managers ensure that clinical employees who perform or assist with moderate sedation procedures have current training for the provision of moderate sedation care, that training is documented, and that clinical managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinical teams keep resuscitation equipment in moderate sedation procedure rooms/areas and that clinical managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
No. 18
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 for community nursing home oversight and monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior and a disruptive behavior reporting and tracking system.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility collect and analyze data from disruptive or violent behavior incidents.
No. 21
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. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers ensure clinicians review the continuing need for Patient Record Flags every 2 years and document the review.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure appropriate individuals conduct debriefings after incidents of disruptive or violent behavior and monitor compliance.
No. 24
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.