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Comprehensive Healthcare Inspection Program Review of the VA Pittsburgh Healthcare System, Pennsylvania

Report Information

Issue Date
Report Number
18-01154-27
VISN
State
Ohio
Pennsylvania
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
4
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 Pittsburgh Healthcare System. 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 Facility leaders, permanently appointed staff who have been working as a team since January 2016, supported patient safety, quality care, and other positive outcomes. However, the presence of organizational risk factors, as evidenced by Patient Safety Indicator data and root cause analyses, may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. The leadership team was knowledgeable about selected SAIL metrics and should continue to take actions to maintain and improve care and performance of selected Quality of Care and Efficiency metrics that are likely contributing to the current “4-Star” rating. The OIG noted findings in two of the eight clinical areas reviewed and issued four recommendations that are attributable to the Deputy Director and Chief of Staff. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (2) Environment of Care • Facility and CBOC environmental cleanliness and maintenance • Inpatient mental health safety

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 that the Medical Executive Board uses the results of Focused Professional Practice Evaluations in the decision to recommend continuation of initially granted privileges and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures service chiefs complete all required elements, including minimum required specialty criteria for Ongoing Professional Practice Evaluations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Deputy Director ensures that a safe and clean environment is maintained throughout the Facility and Westmoreland County Community Based Outpatient Clinic and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Deputy Director ensures the flooring in the mental health seclusion rooms provides cushioning.