Comprehensive Healthcare Inspection of the VA Maryland Health Care System, Baltimore, Maryland

Report Information

Issue Date
Report Number
19-00016-61
VISN
5
State
Maryland
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Medical Staff Privileging Credentialing
Major Management Challenges
Healthcare Services
Recommendations
23
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 VA Maryland Health Care System, Baltimore, Maryland, covering 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. Executive leadership appeared relatively stable. Employee satisfaction scores were generally better than VHA averages; however, patient experience results identified improvement opportunities. Leaders appeared to support efforts to improve and maintain patient safety, quality care, and positive outcomes. Review of accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. Leaders were knowledgeable of Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to act to improve performance measures contributing to the current SAIL ratings. The OIG issued 23 commendations for improvement: (1) Quality, Safety, and Value • Peer review processes • Interdisciplinary review of utilization management data • Root cause analysis processes • Compliance with life-sustaining treatment orders • Review of resuscitative episodes (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes • Reprivileging processes (3) Environment of Care • Environmental cleanliness • Furniture and equipment condition • Infection prevention and control • Panic alarm installation and testing (4) Medication Management: Controlled Substances Inspections • Monthly controlled substances inspections • Emergency drug cache inspections (5) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • Military sexual trauma training (6) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee core membership • Tracking and monitoring cervical cancer data

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 ensures that peer reviews are completed within 120 calendar days or that a written extension is requested and approved by the facility director and monitors peer review coordinator’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures reporting of peer review data to the Executive Council of the Medical Staff at least quarterly and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that all applicable deaths occurring within 24 hours of admission undergo a peer review and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the patient safety manager or designee includes all required components in each root cause analysis to ensure quality and consistency of reviews and monitors the patient safety manager’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the patient safety manager or designee provides feedback about root cause analysis actions to the reporting individuals or departments and monitors patient safety manager’s compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that resuscitative actions performed by staff are in accordance with life-sustaining treatment orders and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and the reviews include required elements and monitors committee’s compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures the service chiefs document the focused professional practice evaluation results in the provider’s profile and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that the facility’s Executive Committee of the Medical Staff Professional Standards Board reviews all data when recommending continuation of provider privileges and monitors the Committee’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that service chiefs include reviews of relevant data in professional practice evaluations when determining continuation of provider’s privileges and monitors service chiefs’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures the service chiefs include service-specific criteria in professional practice evaluations and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director ensures that areas used by patients are clean and safe and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director confirms that damaged furniture and wheelchairs are repaired or removed from service and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the basement tunnel at Perry Point VA is free from water hazards and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director certifies that panic alarms are installed and tested as required and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director ensures that panic alarms on the locked mental health unit are tested to include VA police response time and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that controlled substances inspectors verify controlled substances orders monthly for each medication dispensing cabinet and monitors inspectors’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that monthly reconciliation of one-day dispensing from pharmacy to every automated dispensing cabinet and one day return of stock to pharmacy from every automated dispensing cabinet is performed during controlled substances inspections and monitors compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that controlled substances inspectors complete emergency drug cache inspections, including verification of lock numbers, and monitors inspectors’ compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility director makes certain that primary care and mental health providers complete mandatory military sexual trauma training within the required time frame and monitors providers’ compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the Women Veterans Health Committee is comprised of required core members and monitors committee’s compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that there is a defined process in place and designated staff responsible for tracking and monitoring of cervical cancer screenings as required and monitors compliance.