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Comprehensive Healthcare Inspection Program Review of the VA Puget Sound Health Care System, Seattle, Washington

Report Information

Issue Date
Report Number
18-00334-164
VISN
State
Washington
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
5
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 VA Puget Sound Health Care System (the Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The OIG also provided crime awareness briefings to 75 employees. The Facility’s leadership team is relatively new. With the exception of the Acting Assistant Director, the executive leaders have been working together as a team since October 2017. 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 OIG’s review of survey data suggested generally satisfied employees, opportunities appear to exist to improve outpatient experiences. The senior leadership team was knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance likely contributing to the two-star ranking. The OIG noted findings in two of the eight areas of clinical operations reviewed and issued five recommendations that are attributable to the Director, Chief of Staff, Deputy Director, and Assistant Director. The identified areas with deficiencies are: (1) Environment of Care • Environment of care rounds attendance • Medical equipment safety • Infection Prevention Committee’s discussion and documentation of on-going construction activities • Temperature monitoring in dry food storage areas (2) Medication Management: Controlled Substances Inspection Program • Reconciliation of controlled substances dispensing and return of stock

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 Deputy Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Deputy Director ensures all medical equipment at the South Sound VA Clinic is identified as safe for patient use and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures the Infection Control Committee consistently documents discussions of on-going construction activities and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Assistant Director ensures temperature monitoring occurs in dry food storage areas and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures that reconciliation of controlled substance refills to automated dispensing units in patient care areas and returns to pharmacy stock are performed during controlled substance inspections and monitors compliance.