Clinical Assessment Program Review of the Montana VA Health Care System, Fort Harrison, Montana

Report Information

Issue Date
Report Number
16-00573-309
VISN
State
Montana
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
19
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) evaluated the quality of care delivered at the Montana VA Health Care System. OIG reviewed 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 (CNH) Oversight; and Management of Disruptive/Violent Behavior. OIG provided crime awareness briefings to 82 employees. OIG identified certain system weaknesses in environmental cleanliness; reusable medical equipment processes; anticoagulation processes; transfer data collection; point-of-care testing; moderate sedation policy, processes, and training; CNH annual reviews and clinical visits; disruptive/violent behavior management policy and processes; the surgical death review process; pressure ulcer documentation; and medication reconciliation and patient education for fluoroquinolones. As a result of this review, OIG could not gain reasonable assurance that the facility: (1) Does not have stained or missing ceiling tiles in patient care areas (2) Has effective processes for reusable medical equipment reprocessing (3) Has a comprehensive anticoagulation therapy management program (4) Uses patient transfer data to improve care (5) Appropriately manages critical point-of-care test values (6) Has effective processes for reporting adverse events and ensuring training for moderate sedation (7) Completes exclusion review documentation and performs cyclical reviews of CNH program patient care (8) Effectively manages disruptive/violent behavior (9) Tracks and reviews surgical deaths (10) Documents required elements related to pressure ulcers (11) Includes fluoroquinolones in medication reconciliation and medication counseling and evaluates patient understanding OIG made recommendations in the following seven areas: (1) Environment of Care, (2) Medication Management, (3) Coordination of Care, (4) Diagnostic Care, (5) Moderate Sedation, (6) CNH Oversight, and (7) Management of Disruptive/Violent Behavior. OIG made repeat recommendations in Quality Management, Pressure Ulcer Prevention and Management, and Medication 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 the facility replace missing and stained ceiling tiles in patient care areas and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure standard operating procedures for colonoscopes and endoscopes for esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography are consistent with the manufacturers’ instructions for use.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Sterile Processing Service employees document positive quality control testing results for colonoscopes and endoscopes for esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography in a manner that allows tracking of actions taken and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility provide patients with a direct telephone number for anticoagulation-related calls during normal business hours and define a process for anticoagulation calls outside normal business hours.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility designate a physician anticoagulation program champion.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently provide transition follow-up to inpatients with newly prescribed anticoagulant medications in accordance with local policy 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 and report data on patient transfers out of the facility.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians take and document 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 facility process adverse events/complications in a similar manner as operating room anesthesia adverse events and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility note the absence of adverse events in Operative and Invasive Procedure Committee reports and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinical managers ensure clinical employees who perform or assist with moderate sedation procedures have current Talent Management System training for the provision of moderate sedation care, ensure the training is documented, and monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the policy on ensuring correct surgery and invasive procedures to include all elements of the timeout checklist required by Veterans Health Administration Directive 1039.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers complete exclusion review documentation when community nursing home annual reviews note four or more exclusionary criteria.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure social workers conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the workplace violence prevention policy to include required membership for the Disruptive Behavior Committee.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters Patient Record Flags into the electronic health records.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement a process to ensure all surgical deaths are tracked and reviewed by appropriate clinical employees.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that acute care employees accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinic employees document in patients’ electronic health records medication reconciliation that includes the newly prescribed fluoroquinolone, patient counseling/education that includes the fluoroquinolone, and evaluation of the patients’ level of understanding of the education.