Comprehensive Healthcare Inspection Program Review of the Minneapolis VA Health Care System, Minneapolis, Minnesota

Report Information

Issue Date
Report Number
17-01755-61
VISN
State
Minnesota
Wisconsin
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
18
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 delivered at the Minneapolis VA Health Care System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home (CNH) Oversight. OIG provided crime awareness briefings to 26 employees. The facility has generally stable executive leadership and active engagement with employees and patients to maintain high satisfaction scores. Organizational leadership supports patient safety, quality care, and other positive outcomes. The senior leadership team was knowledgeable of insightful and important metrics that reflect upon their leadership qualities and activities taken to improve or sustain performance of selected metrics. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors. OIG noted findings in the six areas of clinical operations reviewed and issued 18 recommendations. The identified areas with deficiencies are: (1) QSV • Implementation of Peer Review Committee actions • Completion of utilization management reviews and documentation of decisions • Annual patient safety report • Committee meeting minutes (2) Medication Management: Anticoagulation Therapy • Inclusion of required elements in facility policy • Quality assurance data • Staff competency assessments (3) Coordination of Care: Inter-Facility Transfers • Inclusion of required elements in facility policy • Documentation for inter-facility transfers (4) EOC • EOC rounds frequency and attendance • Mental health unit staff and Interdisciplinary Safety Inspection Team training  (5) High-Risk Processes: Moderate Sedation • History and physical examination and pre-sedation assessment components • Provision and documentation of informed consent • Performance of timeouts (6) Long-Term Care: CNH Oversight • Oversight committee participation • Monthly cyclical clinical visits

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)
The Chief of Staff ensures clinical managers consistently implement and document actions recommended by the Peer Review Committee and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures completion of at least 75 percent of all required inpatient utilization management reviews and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors advisors’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures the Patient Safety Manager submits an annual patient safety report to facility leaders at the completion of each fiscal year and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director and Chief of Staff ensure that Executive Leadership Board and Peer Review Committee meeting minutes accurately reflect action status and that items are tracked to closure and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services ensures the anticoagulation management program policy is revised to include the transition of patients between the inpatient and outpatient care settings and an anticoagulation quality assurance program.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff and Associate Director for Patient Care Services ensure that anticoagulation management program quality assurance data from all sites of care are collected, analyzed, and reported biannually to the Pharmacy and Therapeutics Committee and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services ensures that annual anticoagulation management program competency assessments include all required content and that employees assigned to this program complete competency assessments as required and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures the facility’s revised inter-facility transfer policy includes all required elements.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that for patients transferred out of the facility, providers consistently document patient or surrogate informed consent, medical and behavioral stability, and identification of transferring and receiving provider or designee and monitors providers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that for patients transferred out of the facility, providers document sending or communicating to the accepting facility pertinent patient information and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Operations ensures designated team members conduct environment of care rounds in clinical and nonclinical areas as required and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Operations ensures all locked mental health unit employees and Interdisciplinary Safety Inspection Team members receive annual training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that providers include an airway assessment and history of previous adverse experience with sedation or anesthesia in the history and physical exam and/or pre-sedation assessment and monitors the providers’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that providers provide and document informed consent prior to moderate sedation administration and monitors providers’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures clinical teams conduct and document timeouts prior to moderate sedation procedures, the privileged provider participates in the timeout, and staff use a checklist that includes all required elements and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures Community Nursing Home Oversight Committee meetings include participation by all required disciplines and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services ensures the social workers and registered nurses conduct monthly cyclical clinical visits and monitors compliance.