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Comprehensive Healthcare Inspection of the Cheyenne VA Medical Center, Wyoming

Report Information

Issue Date
Report Number
18-04680-162
VISN
State
Colorado
Nebraska
Wyoming
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
17
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Cheyenne VA Medical Center. The inspection covers leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility’s executive leadership team appeared relatively stable; and efforts to continually improve and maintain positive outcomes, patient safety, and quality care were noted. Patients appeared generally satisfied with the leadership and care provided, but opportunities exist for the leaders to improve employee satisfaction. Review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to improve performance of measures that are likely contributing to the current SAIL “2-star” and CLC “3-star” quality ratings. The OIG issued 17 recommendations for improvement in the following areas: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data • Root cause analyses and resuscitation episode reviews (2) Medical Staff Privileging • Ongoing professional practice evaluation process (3) Environment of Care • Environmental cleanliness • Infection prevention • Emergency management (4) Mental Health • MST coordinator responsibilities • MST training (5) Geriatric Care • Patient/caregiver education and understanding of medications (6) Women’s Health • Women veterans health committee core membership (7) High-risk Processes • Labeling open medication vials in the emergency department with expiration dates

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 the interdisciplinary group or committee that reviews utilization management data includes a representative from the chief business office revenue utilization review and monitors the committee’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the patient safety manager includes all required review elements in root cause analyses and monitors the patient safety manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the Critical Care Committee conducts a complete analysis of resuscitation episodes by reviewing required elements and monitors the committee’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures service chiefs collect, review, and use ongoing professional practice evaluation data in the determination to continue current privileges and monitors the service chiefs’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain service chiefs include the minimum required specialty-specific criteria for ongoing professional practice evaluations of gastroenterology practitioners and monitors service chiefs’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director ensures managers maintain a safe and clean environment in patient care areas and monitors managers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director ensures managers make personal protective equipment readily accessible to employees at the Rawlins VA Clinic and monitors managers’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director makes certain that the hazard vulnerability analysis is reviewed annually and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director confirms that the emergency operations plan is activated twice a year and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the military sexual trauma coordinator establishes and monitors military sexual trauma-related staff training and monitors the coordinator’s compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma-related services and initiatives with leadership and monitors the coordinator’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the military sexual trauma coordinator tracks and monitors military sexual trauma-related data and monitors the coordinator’s compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that providers complete military sexual trauma mandatory training within the required timeframe and monitors providers’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that clinicians provide and document patient/caregiver education and assess understanding of education provided about newly prescribed medications and monitors clinicians’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the Women Veterans Health Committee includes required core members and monitors the committee’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director for Patient Care Services makes certain that staff label multi-dose medication vials with an expiration date upon opening and monitors clinical staff’s compliance.