Comprehensive Healthcare Inspection of the Manchester VA Medical Center, New Hampshire

Report Information

Issue Date
Report Number
19-00040-10
VISN
State
New Hampshire
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 provides a focused evaluation of the quality of care at the Manchester 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 Care; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results; and High-Risk Processes: Emergency Department/Urgent Care Center Operations. The facility’s leadership team is generally stable and has active engagement with employees and patients as evidenced by high satisfaction scores. Leaders supported efforts related to safety and quality care; however, the OIG identified a substantial organizational risk—the lack of available support services. Specifically, the OIG is concerned with the urgent care clinic’s lack of access to on-site support services during evenings, nights, weekends, and holidays and limited availability of staff to provide consistent and immediate advanced airway support for cardiopulmonary resuscitation events. The leaders were knowledgeable about Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to improve care and performance of quality of care metrics contributing to current SAIL ratings. The OIG issued 17 recommendations for improvement: (1) Quality, Safety, and Value • Review of literature for root cause analyses (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (3) Environment of Care • Maintenance of a clean and safe environment (4) Mental Health • Military sexual trauma referrals, training, and communication of initiatives (5) Geriatric Care • Justification for medication and reconciliation • Caregiver/patient medication education (6) Women’s Health • Communication of abnormal results to patients (7) Emergency Departments and Urgent Care Center Operations • Urgent Care Center registered nurse staffing • Backup call schedule for Urgent Care Center providers • Availability of support services

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 confirms that the patient safety manager includes consideration of relevant literature in root cause analyses and monitors patient safety manager’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that clinical managers document in practitioners’ profiles the focused professional practice evaluation criteria defined in advance and monitors clinical managers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that professional practice evaluations include service-specific criteria and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that specialty providers’ ongoing professional practice evaluations include the minimum required specialty criteria and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that the facility’s Medical Executive Council reviews the professional practice data in the consideration to continue provider privileges and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that professional practice evaluations are completed by a provider 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 clean and safe environment is maintained throughout the facility and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that military sexual trauma coordinator communicates the status of military sexual trauma-related information to leadership and monitors coordinator’s compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures providers offer referrals for military sexual trauma-related services for patients with a positive screen and monitors providers’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms 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 providers document indication for use for newly prescribed medications in patients’ electronic health records and monitors providers’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that clinicians provide and document patient/caregiver education and understanding of education provided about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures providers reconcile medication information and resolve discrepancies and monitors the providers’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the urgent care center is staffed with at least two registered nurses at all times of operation and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that a backup call schedule is maintained for urgent care center providers and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that support services necessary to care for patients are readily available to the urgent care center during all hours of operation and monitors compliance.