Breadcrumb

Comprehensive Healthcare Inspection of the Sioux Falls VA Health Care System, South Dakota

Report Information

Issue Date
Report Number
19-00019-26
VISN
State
Iowa
South Dakota
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
8
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 Sioux Falls VA Health Care System, 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; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. At the time of the OIG’s review, three of four executive leaders were serving in an acting capacity. The facility leaders appeared actively engaged with employees and patients and were working to sustain and further improve employee and patient engagement and satisfaction. The leaders also appeared to support efforts to improve and maintain patient safety, quality care, and other positive outcomes. 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. However, opportunities appear to exist for the leaders to improve their knowledge about and to continue to take actions to sustain and improve selected performance of measures contributing to the Strategic Analytics for Improvement and Learning “4-star” and Community Living Center “1-star” quality ratings. The OIG issued eight recommendations for improvement in the following areas: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data (2) Medical Staff Privileging • Specialty-specific criteria for focused professional practice evaluations (3) Environment of Care • Infection prevention (4) Medication Management • Verification of controlled substance orders substances (5) Mental Health • Military sexual trauma training (6) Geriatric Care • Patient/caregiver education on medications (7) Women’s Health • Women Veterans Health Committee core membership (8) High-risk Processes • Emergency department registered nurse staffing

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 chief of staff ensures that the imaging service chief includes the minimum required specialty-specific criteria for focused professional practice evaluations of nuclear medicine practitioners and monitors imaging service chief’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director confirms that facility managers replace or remove damaged furnishings and wheelchairs from service and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the controlled substances inspectors and coordinator carry out all required responsibilities for the verification of controlled substance orders and monitors inspectors’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 6
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 caregivers education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the emergency department is staffed with a minimum of two registered nurses during all hours of operation and monitors compliance.