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Clinical Assessment Program Review of the Michael E. DeBakey VA Medical Center, Houston, Texas

Report Information

Issue Date
Report Number
16-00552-341
VISN
State
Texas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
12
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 Michael E. DeBakey VA Medical Center. This included reviews 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 171 employees. OIG identified certain system weaknesses in utilization management; environmental cleanliness; anticoagulation processes and staff competency; employee competencies for point-of-care testing; community nursing home committee representation, annual reviews, and cyclical monthly documentation; and establishment of an Employee Threat Assessment Team and employee training for management of disruptive/violent behavior. As a result of the findings, OIG could not gain reasonable assurance that: 1. Facility managers effectively monitor the documentation of physician advisors’ decisions in the required database. 2. Facility managers maintain clean floors and patient rolling equipment and ensure damaged patient rolling equipment is repaired. 3. The facility reviews quality assurance data for the anticoagulation management program, clinicians obtain all required laboratory testing prior to initiating anticoagulants, and employees involved in the anticoagulant program complete competency assessments. 4. The facility develops and implements employee competencies for glucometer point-of care testing and assesses competencies annually. 5. Facility managers ensure required disciplines participate in Community Nursing Home Oversight Committee functions, monitor the community nursing home program, and assure the safe care of patients in those homes. 6. The facility has an Employee Threat Assessment Team, and employees receive training to reduce and prevent disruptive behaviors. OIG made recommendations for improvement in the following six review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management; (4) Diagnostic Care; (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 Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database 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 floors and rolling equipment in patient care areas are clean and in good repair and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility review quality assurance data for the anticoagulation management program monthly at Pharmacy and Therapeutics Committee meetings and that facility managers monitor compliance.
No. 4
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 anticoagulants.
No. 5
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 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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the laboratory director develop and implement a process to ensure employee competency for point-of-care testing with glucometers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the laboratory director 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 facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews and monitor compliance.
No. 10
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 visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
No. 11
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.
No. 12
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.