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Comprehensive Healthcare Inspection Program Review of the William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina

Report Information

Issue Date
Report Number
18-00412-173
VISN
State
South Carolina
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
8
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 William Jennings Bryan Dorn VA Medical Center (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 Facility has stable executive leadership and active engagement with employees as evidenced by high satisfaction scores. Organizational leaders support patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the Facility through active stakeholder engagement). The OIG’s review of accreditation organization findings, sentinel events, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. The senior leadership team was actively engaged and knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance of selected SAIL metrics, particularly Quality of Care and Efficiency metrics likely contributing to the “2-Star” rating. The OIG noted findings in four of the eight areas of clinical operations reviewed and issued eight recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are: 1) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes 2) Environment of Care • Core members’ participation in environment of care rounds • Environmental cleanliness • Medical equipment safety 3) Mental Health Care • Timely completion of suicide risk assessments 4) Long-Term Care • Geriatric evaluation program performance improvement and oversight • Identification and implementation of geriatric plan of care interventions

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 Service Chiefs complete required elements of Focused Professional Practice Evaluations for review by the Medical Executive Board and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that Service Chiefs include all required elements for Ongoing Professional Practice Evaluations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures all required team members consistently participate on environment of care rounds and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures that Facility managers maintain a safe and clean environment throughout the Facility and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures all medical equipment is identified as safe for patient use and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures providers complete suicide risk assessments, within the required timeframe, for patients with positive Post-Traumatic Stress Disorder screens and monitors providers’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that geriatric evaluation program performance improvement activities are presented to an appropriate leadership board and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that clinicians accurately identify and implement the Geriatric Evaluation plan of care interventions and monitors compliance.