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Comprehensive Healthcare Inspection of the Hunter Holmes McGuire VA Medical Center, Richmond, Virginia

Report Information

Issue Date
Report Number
18-04679-239
VISN
State
Virginia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
21
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 at the Hunter Holmes McGuire VA Medical Center, covering leadership, organizational risks, and key processes associated with promoting quality care. 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 had generally stable executive leadership, but the OIG had concerns with long-term Nursing Service leadership vacancies and minimal recruitment efforts. Employee satisfaction and patient experiences in the inpatient and specialty care settings also need improvement. The leadership team should review steps to identify cases that may need institutional disclosures and evaluate the process of identifying improvement opportunities. The leadership team needs to improve their knowledge about selected SAIL and CLC metrics and the actions necessary to sustain and improve performance that contribute to the SAIL “4-star” and CLC “1-star” quality ratings. The OIG issued 21 recommendations: (1) Quality, Safety, and Value • Physician utilization management advisors’ documentation • Root cause analyses • Resuscitative episode reviews (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (3) Environment of Care • General cleanliness and safety (4) Controlled Substances Inspections • Controlled substances inventories/checks, documentation, and reconciliation • Pharmacy inspections and medication destruction • Verification of prescription pads and written prescriptions (5) Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (6) Antidepressant Use among the Elderly • Patient/caregiver education and understanding of medications • Medication reconciliation (7) Abnormal Cervical Pathology Results Notification and Follow-up • Full-time women veterans program manager (8) Emergency Departments and Urgent Care Center Operations • Licensed mental health provider availability • Directional signage

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 physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database and monitors advisors’ compliance
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the patient safety manager includes all required content in root cause analyses and monitors patient safety manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain the Code Blue Committee reviews each resuscitative episode under the facility’s responsibility and monitors Code Blue Committee’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that clinical managers initiate focused professional practice evaluations that include clearly delineated criteria and time frames in advance and monitors clinical managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that focused professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that the Medical Professional Standards Committee reviews and evaluates licensed independent practitioners’ professional practice evaluations when recommending approval of privileges through the Medical Executive Council to the director and monitors committee’s compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that service chiefs consistently collect and review ongoing professional practice evaluation data and monitors service chiefs’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director ensures that a safe and clean environment is maintained throughout the facility and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the controlled substance inspectors conduct the monthly inventories of controlled substances and the controlled substances coordinator maintains supporting documentation of the completion of the monthly inventory of controlled substances and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that controlled substances program staff reconcile one day’s dispensing from the pharmacy to each dispensing area and one day’s return of stock to the pharmacy and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that controlled substances inspectors complete the pharmacy monthly controlled substances inspection inventory on the day initiated and monitors inspectors’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that during monthly inspections, controlled substances inspectors verify that each medication listed on the “Destructions File Holding Report” is contained in a corresponding sealed evidence bag and monitors compliance of controlled substance inspection staff.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that controlled substances inspectors and coordinator carry out all responsibilities for the verification of pharmacy prescription pad counts during monthly pharmacy inspections and monitors controlled substances inspections staff compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the controlled substances inspectors and coordinator carry out all required responsibilities for the verification of written controlled substances prescriptions during monthly area inspections and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that controlled substances inspectors and coordinator carry out responsibilities for the 72-hour pharmacy inventory checks as required and monitors compliance.
No. 16
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 time frame and monitors providers’ compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education and assess understanding of education provided specific to newly prescribed medications and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures clinicians review and reconcile medications and monitors clinicians’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the women veterans program manager position is full time and monitors compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures the emergency department has an independent licensed mental health provider available as required for 1a facilities and monitors compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that sufficient signage assists and directs patients in locating the emergency department and monitors compliance.