Report Summary

Title: Comprehensive Healthcare Inspection Program Review of the Mann-Grandstaff VA Medical Center, Spokane, Washington
Report Number: 18-01144-24 Download
Issue Date: 12/6/2018
City/State: Spokane, WA
Coeur d'Alene, ID
Ponderay, ID
Ponderay, ID
Libby, MT
Libby, MT
Wenatchee, WA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

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 Mann-Grandstaff VA Medical Center. 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: Posttraumatic 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 executive leadership team has been working together since November 2017, when the Director was appointed. Overall, the OIG noted that employees and patients appeared satisfied with the leadership team and the care provided. Organizational leaders appeared to support patient safety and quality care. However, OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results identified a seemingly high number of institutional disclosures for this low complexity facility, which could be a potential risk factor if not reviewed and monitored.

The OIG noted findings in five of the eight areas of clinical operations reviewed and issued seven recommendations that are attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are:

(1) Quality, Safety, and Value

• Interdisciplinary review of utilization management data

(2) Credentialing and Privileging

• Ongoing Professional Practice Evaluation process

(3) Environment of Care

• Biohazardous waste storage

• Panic alarm testing and response time documentation

• Emergency Operations Plan annual review

(4) Long-term Care: Geriatric Evaluations

• Program oversight

(5) High-risk Processes: Central Line-associated Bloodstream Infections

• Staff education