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Comprehensive Healthcare Inspection Program Review of the VA Northern California Health Care System, Mather, California

Report Information

Issue Date
Report Number
17-01750-97
VISN
State
California
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
13
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 VA Northern California 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 also provided crime awareness briefings to 404 employees. The facility has generally stable executive leadership to support patient safety, quality care, and other positive outcomes; however, leaders should continue to take actions to improve outpatient satisfaction scores. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to improve performance of the Quality of Care and Efficiency metrics likely contributing to the current 2-star SAIL rating. OIG noted findings in the six areas of clinical operations reviewed and issued 13 recommendations that are attributable to the Chief of Staff and Associate Directors. The identified areas with deficiencies are: (1) QSV • Peer review process • Review of Ongoing Professional Practice Evaluation data (2) Medication Management: Anticoagulation Therapy • Anticoagulation management policy • Laboratory testing • Employee competency assessments (3) Coordination of Care: Inter-Facility Transfers • Patient transfer documentation (4) EOC • EOC rounds attendance • Security surveillance television system testing • Locked mental health unit employee and Interdisciplinary Safety Inspection Team training  (5) High-Risk Processes: Moderate Sedation • Assessments of previous history/experience with sedation • Timeout checklist (6) Long-Term Care: CNH Oversight • Annual reviews • Monthly 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 peer reviewers consistently use at least one of the important aspects of care to evaluate peer review findings and monitors reviewers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures service chiefs consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the service chiefs’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures pharmacy managers implement an anticoagulation management standard operating procedure that contains all elements required by the Veterans Health Administration.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications and monitors clinicians’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures clinical managers include all required elements in competency assessments for employees actively involved in the anticoagulant program and monitors managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures clinicians consistently include patient or surrogate informed consent in transfer documentation and monitors clinicians’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Directors ensure required team members participate on environment of care rounds and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures VA Police conduct required testing of the locked mental health unit security surveillance television system and monitors VA Police compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures all locked mental health unit employees and Interdisciplinary Safety Inspection Team members complete the required training on identification and correction of environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures providers include the history of previous experience with sedation and anesthesia in the history and physical exams and/or pre-sedation assessments and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures clinical teams use a checklist that includes all required elements to conduct and document timeouts prior to moderate sedation procedures and monitors the teams’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures the Community Nursing Home Review Team completes required annual reviews and monitors the team’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures social workers and registered nurses conduct cyclical clinical visits with the frequency required and monitors social workers’ and registered nurses’ compliance.