Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center, Alabama

Report Information

Issue Date
Report Number
19-00057-238
VISN
State
Alabama
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
14
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 Tuscaloosa VA Medical Center, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas 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; and Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up. The facility’s executive leadership team appeared relatively stable; and, upon review of the facility’s accreditation findings, sentinel events, and disclosures, the OIG did not identify any substantial organizational risk. However, the OIG had concerns regarding the root cause analysis process—corrective actions were not implemented or, if implemented, not measured, allowing existing system vulnerabilities that were not eliminated or controlled and exposing veterans to potential and preventable adverse events. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics and should continue to take actions to improve performance contributing to the SAIL “3-star” and CLC “2-star” quality ratings. The OIG issued 14 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary utilization management data review • Root cause analysis processes (2) Medical Staff Privileging • Ongoing professional practice evaluation process (3) Environment of Care • General safety and cleanliness • Mental health unit panic alarm testing response times • Comprehensive emergency management plan annual review (4) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (5) Antidepressant Use among the Elderly • Medication reconciliation (6) Abnormal Cervical Pathology Results Notification and Follow-up • Assignment of a women’s health medical director • Women Veterans Health Committee core membership • Patient notification of abnormal results

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 makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director requires the patient safety manager to ensure completion of the required minimum of eight root cause analyses each fiscal year 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 that the patient safety manager or designee includes all the required elements in root cause analyses and monitors patient safety manager’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that managers consistently implement improvement actions arising from root cause analysis activities and evaluate actions taken for sustained improvement and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the patient safety manager or designee provides feedback to individuals or departments who submit patient safety incidents that result in root cause analysis and monitors patient safety manager compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures ongoing professional practice evaluations utilize assessments 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 that a safe and clean environment is maintained throughout the facility and Selma VA Clinic and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director ensures the VA police respond to panic alarm testing in the locked mental health unit and document response time and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director ensures that the comprehensive emergency management plan is reviewed annually by the Emergency Management Committee and approved by executive leadership and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures clinicians review and reconcile patients’ medications and maintain and communicate accurate patient medication information in patients’ electronic health record and monitors clinicians’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The director makes certain that the chief of staff assigns a women’s health medical director or clinical champion and monitors chief of staff’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that the Women Veterans Health Committee includes required core members and monitors committee’s compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that providers notify patients of abnormal cervical pathology results within the required time frame and monitors providers’ compliance.