Comprehensive Healthcare Inspection Summary Report Fiscal Year 2018

Report Information

Issue Date
Report Number
19-07040-243
VISN
State
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
16
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 by randomly selected Veterans Health Administration (VHA) facilities. The inspection covers key processes associated with promoting quality care, including Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Posttraumatic Stress Disorder; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The Office of Inspector General (OIG) noted that 85 percent of leaders were assigned permanently at the 51 VA facilities visited from October 2017 through September 2018. These facility leaders generally appeared engaged in supporting quality, felt supported by VISN leaders, were aware of improvement efforts for employee and patient satisfaction, and actively addressed Joint Commission and OIG recommendations for improvement. Sixteen of the surveyed facilities with a “1-” or “2-star” Strategic Analytics for Improvement and Learning (SAIL) star rating had significant opportunities for improvement, and facilities with higher SAIL star ratings had fewer OIG recommendations for improvement. The OIG issued 16 recommendations for improvement: (1) Quality, Safety, and Value • Implementation of peer review improvement actions • Physician utilization management advisors’ inpatient stay reviews • Interdisciplinary utilization management data reviews • Feedback for root cause analysis actions (2) Credentialing and Privileging • Reporting of focused professional practice evaluations (FPPEs) to an appropriate committee of the medical staff • Clearly delineated timeframes in FPPEs • Service-specific data in ongoing professional practice evaluations (OPPEs) • Specialty-specific elements in selected specialty providers’ OPPEs (3) Environment of Care • Environmental cleanliness • Panic alarms testing • Floor cushioning in mental health unit seclusion rooms • Emergency operations plan/processes (4) Controlled Substances Inspections • Correction of deficiencies from annual physical security surveys • One-day reconciliation of stock between pharmacy and dispensing areas • Monthly controlled substances inspections (5) Geriatric evaluation program oversight/evaluation

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 Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure that clinical managers consistently implement improvement actions recommended from peer review activities and monitor clinical managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, confirm that physician utilization management advisors document the minimum required percentage of all inpatient stay reviews in the National Utilization Management Integration database and monitor physician advisors’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, make certain that an interdisciplinary group or committee, that includes all required representatives, consistently reviews utilization management data and monitor committees’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure that clinical managers provide feedback about root cause analysis actions to the individuals or departments who reported the incidents and monitor clinical managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that clinical managers report completed focused professional practice evaluations to an appropriate committee of the medical staff and monitor clinical managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that clinical managers clearly delineate time frames in focused professional practice evaluations and monitor clinical managers’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that clinical managers include service-specific data in ongoing professional practice evaluations and monitor clinical managers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that clinical managers include specialty-specific elements in gastroenterology, pathology, nuclear medicine, and radiation oncology providers’ ongoing professional practice evaluations and monitor clinical managers’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure that managers maintain a clean and safe environment throughout the facilities and monitor managers’ compliance.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, confirm that VA Police test panic alarms and document response times to alarm testing in locked mental health units and high-risk outpatient clinic areas and monitor VA Police compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, make certain that facility managers install floor cushioning in locked mental health unit seclusion rooms and monitor facility managers’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that facility managers annually review emergency operations plans and resource and asset inventories and monitor facility managers’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, confirm that facility managers correct identified deficiencies from annual physical security surveys and monitor facility managers’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that controlled substances coordinators reconcile one-day’s dispensing from the pharmacy to every automated dispensing cabinet and returns to pharmacy stock from each dispensing area during controlled substances inspections and monitor controlled substances coordinators’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, make certain that controlled substances coordinators refrain from routinely conducting monthly controlled substances inspections and monitor controlled substances coordinators’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network Directors and facility senior leaders, ensure that facility managers conduct and report geriatric evaluation program performance improvement activities to an appropriate leadership board and monitor facility managers’ compliance.