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Comprehensive Healthcare Inspection of the Fargo VA Health Care System, North Dakota

Report Information

Issue Date
Report Number
19-00018-252
VISN
State
Minnesota
North Dakota
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
5
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 Fargo VA Health Care System. 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 with all four positions permanently filled for longer than one year prior to the OIG’s visit. For selected employee and patient experience survey scores, the OIG noted that employees and patients were generally satisfied. The facility leaders appeared actively engaged and were working to sustain and further improve employee and patient engagement and satisfaction. The OIG’s review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. The leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “4-star” and CLC “2-star” quality ratings, respectively. The OIG issued five recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data (2) Medical Staff Privileging • Use of ongoing professional practice evaluations for reprivileging decisions (3) Mental Health: Military Sexual Trauma Follow-up and Staff Training • Military sexual trauma training (4) High-risk Processes: Emergency Departments and Urgent Care Center Operations • Emergency department registered nurse staffing • Backup call schedule for emergency department providers

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 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 chief of staff ensures that the Medical Executive Committee evaluates providers’ reprivileging requests based on ongoing professional practice evaluation results, and meeting minutes consistently reflect the decision to recommend continuation of ongoing privileges and monitors committee’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the emergency department is staffed by a minimum of two registered nurses during all hours of operation and monitors the department’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that the chief of emergency department maintains a written backup call schedule for emergency department providers and monitors emergency department chief’s compliance.