Comprehensive Healthcare Inspection Program Review of the Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington

Report Information

Issue Date
Report Number
17-01746-116
VISN
State
Idaho
Oregon
Washington
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
10
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 in the inpatient and outpatient settings of the Jonathan M. Wainwright Memorial VA Medical Center (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; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; Long-Term Care: Community Nursing Home (CNH) Oversight; and Mental Health Residential Rehabilitation Treatment Program. The OIG also provided crime awareness briefings to 92 employees. Due to past leadership and organizational failures, the facility and its leaders are in a state of transition and face a challenging task of improving the organizational culture. The leaders spoke enthusiastically of ongoing efforts to rebuild workforce and patient trust and engagement, boost employee and patient satisfaction, achieve leadership stability, and improve organizational performance. These actions included actively engaging with and involving employees at all levels and developing an infrastructure with key personnel that will support and sustain organizational transformation. The OIG noted findings in four areas of clinical operations reviewed and issued 10 recommendations that are attributable to the Facility Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are: (1) QSV • Senior-level committee for QSV functions • Annual completion of required root cause analyses (2) Medication Management: Anticoagulation Therapy • Analysis and reporting of quality assurance data • Patient education specific for newly prescribed anticoagulant medications • Laboratory tests completion prior to initiating anticoagulant medications • Staff competency assessments (3) EOC • Frequency of and participation in EOC rounds (4) Long-Term Care: CNH Oversight • Multi-disciplinary participation in Oversight Committee • 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 Facility Director ensures that a senior-level committee is established and responsible for key Quality, Safety, and Value functions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures the Patient Safety Manager completes the required minimum of eight root cause analyses each fiscal year and monitors the manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that anticoagulation management program quality assurance data are analyzed and reported to the Pharmacy and Therapeutics Committee and monitors program managers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and monitors clinicians' compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures clinicians consistently obtain and document all required laboratory tests prior to initiating anticoagulant medications and monitors clinicians' compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures all required elements specific to anticoagulation management are included in competency assessments for employees actively involved in the anticoagulant program and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures environment of care inspections are conducted at the required frequency and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures core team members consistently participate in environment of care rounds and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff and the Nurse Executive ensure that the Community Nursing Home Oversight Committee includes representation by all required disciplines and monitor compliance
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Nurse Executive ensures social workers conduct cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitors social workers’ compliance.