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Alleged Deficiencies in Oncology Psychosocial Distress Screening and Root Cause Analysis Processes at a Facility in VISN 15

Report Information

Issue Date
Report Number
19-06562-30
VISN
State
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
4
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) evaluated the oncology service staff’s adherence to the facility’s psychosocial distress screening standard operating procedure in the care of two patients who died by suicide, and facility leaders’ response to the root cause analyses following the two patients’ deaths. Facility oncology service staff demonstrated compliance with psychosocial distress screening standard operating procedures. However, the OIG was unable to determine if a mental health evaluation completed prior to one of the patients leaving the clinic would have changed the patient’s outcome. Completion of a mental health evaluation may have identified additional risk factors and provided opportunity for suicide prevention interventions prior to the patient leaving the clinic. The National Comprehensive Cancer Network standards of care state a patient should be screened at the initial visit and ideally at every visit. Facility oncology service nursing staff were unclear about when to administer the psychosocial distress thermometer, a self-report tool that evaluates a patient’s distress level, and therefore, administered the tool at every visit. Thus, nursing practice in the facility oncology service exceeded the facility standard operating procedure requirements and provided the National Comprehensive Cancer Network ideal standard of care. The alignment of the standard operating procedure with the ideal standard and current practice is critical to ensure clear guidance to staff regarding the completion of the psychosocial Distress Thermometer. The facility’s Patient Safety Manager did not monitor progress toward root cause analysis action item completion. Following the OIG team’s expressed concern about this deficiency, the Patient Safety Manager implemented a tracking tool that same month. The OIG identified one additional concern. After a patient’s death by suicide in 2017, the Acting Suicide Prevention Coordinator did not complete a Suicide Behavior Report or Behavioral Health Autopsy, as required by Veterans Health Administration.

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 Veterans Integrated Service Network Medical 15 Facility Director conducts an evaluation of radiation oncology clinic mental health consultation and treatment program needs and adjusts mental health provider coverage as warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Integrated Service Network Medical 15 Facility Director ensures that all components of the oncology service psychosocial distress screening standard operating procedures include screening frequency consistent with National Comprehensive Cancer Network’s ideal standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Integrated Service Network Medical 15 Facility Director guarantees that the patient safety program maintains effective processes to track action items to completion and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Integrated Service Network Medical 15 Facility Director ensures that staff complete Suicide Behavior and Overdose Reports and Behavioral Health Autopsies, as required by the Veterans Health Administration.