Comprehensive Healthcare Inspection of the Northern Arizona VA Health Care System, Prescott, Arizona

Report Information

Issue Date
Report Number
19-00014-33
VISN
State
Arizona
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
20
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 Northern Arizona VA Health Care System, covering leadership, organizational risks, and key 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; and 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 leaders were relatively new to their positions. Reviewing the facility’s accreditation findings, sentinel events, and disclosures, the OIG did not identify any substantial organizational risk factors. However, patient experience survey data revealed opportunities for improvement in the Patient-Centered Medical Home outpatient setting. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to take actions to improve performance of measures contributing to the facility’s SAIL “2-star” quality rating. The OIG issued 20 recommendations for improvement: (1) Quality, Safety, and Value • Utilization management processes • Root cause analyses actions • Analyses of resuscitation episodes (2) Medical Staff Privileging • Ongoing professional practice evaluation process (3) Environment of Care • Medication safety (4) Controlled Substances Inspections • Reconciliation for return of stock • Emergency drug cache inspection (5) Military Sexual Trauma Follow-up and Staff Training • MST Coordinator responsibilities • Providers’ training (6) Antidepressant Use among the Elderly • Patient/caregiver education • Medication reconciliation (7) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee requirements • Tracking cervical cancer screening data • Communicating abnormal results to patients (8) Emergency Departments and Urgent Care Center Operations • Backup call schedules for emergency department providers and social workers (9) Incidental Finding • Concentrated opioids storage safety

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 ensures physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
No. 2
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures all root cause analyses actions are fully implemented by assigned staff and monitors the assigned staff’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the Cardiopulmonary Resuscitation Committee conducts complete analyses of resuscitative episodes by reviewing required elements and monitors the committee’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that the Radiology Service chief includes the required nuclear medicine-specific criteria for ongoing professional practice evaluations of nuclear medicine providers and monitors the chief’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director for Patient Care Services ensures that nursing staff label multi-dose medication vials with an expiration date upon opening and monitors staff compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that controlled substances program staff complete reconciliation of one random day’s return of stock to pharmacy from every automated dispensing cabinet during inspections and monitors controlled substances program staff compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures controlled substances inspectors complete emergency drug cache inspections and monitors inspectors’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the military sexual trauma coordinator establishes and monitors military sexual trauma-related staff training.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the military sexual trauma coordinator establishes and monitors informational outreach and monitors the coordinator’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma services and initiatives with leadership and monitors the coordinator’s compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the military sexual trauma coordinator tracks and monitors military sexual trauma-related data and monitors the coordinator’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 14
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 caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures clinicians reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors clinicians’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the Women Veterans Health Committee maintains an active charter, meets at least quarterly, and reports to executive leaders with signed minutes and monitors the committee’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that the women veterans program manager implements a quality assurance process to include tracking of data for cervical cancer screening and results and monitors the manager’s compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff directs the acute care medical director to ensure that a backup call schedule is maintained for emergency department providers and social workers and monitors compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the chief of Pharmacy ensures highly concentrated oral liquid opioid medications are not stored in patient care areas for patient safety and monitors the chief’s compliance.