Report Summary

Title: Comprehensive Healthcare Inspection of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
Report Number: 19-00043-66 Download
Report
Issue Date: 1/13/2020
City/State: Bedford, MA
Haverhill, MA
Lynn, MA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted
Summary:

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at Edith Nourse Rogers Memorial Veterans Hospital (the facility), 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; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations.

The leaders had been working together for approximately 15 months. Selected employee satisfaction results indicated general satisfaction with facility leaders, but opportunities exist to improve workplace attitudes. Leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center metrics but should continue to act to sustain and improve performance measures contributing to the SAIL “5-star” and community living center “2-star” quality ratings.

The OIG issued 21 recommendations for improvement:

(1) Quality, Safety, and Value

• Interdisciplinary review of utilization management data

• Root cause analysis processes

(2) Medical Staff Privileging

• Focused and ongoing professional practice evaluation processes

(3) Environment of Care

• Environmental safety and cleanliness

• Medical supply storage

• Panic alarm testing

• Comprehensive emergency management plan

(4) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training

• Military sexual trauma training

(5) Geriatric Care: Antidepressant Use among the Elderly

• Justification for medication initiation

• Patient and/or caregiver education and evaluation of understanding

• Medication reconciliation processes

(6) Women Health: Abnormal Cervical Pathology Results Notification and Follow-up

• Women Veterans Health Committee membership

(7) High-Risk Processes: Emergency Department and Urgent Care Center Operations

• 24-hour Urgent Care Center operations waiver

• Appointed Urgent Care Center medical director

• Urgent Care Center staffing

• Urgent Care Center support services availability