Report Summary

Title: Comprehensive Healthcare Inspection of the VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
Report Number: 19-00038-63 Download
Issue Date: 1/13/2020
City/State: Leeds, MA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care at the VA Central Western Massachusetts Healthcare 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; 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 leadership team appeared relatively stable, having worked together for 18 months at the time of the inspection. Employee and patient satisfaction scores were better than the VHA average, with some opportunity for improvement. The facility received preliminary denial, but later full accreditation from The Joint Commission. The facility’s accreditation findings, sentinel events, and disclosures identified areas for improvement. The leadership team was knowledgeable of Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics and should continue to act to sustain and improve performance of measures contributing to the SAIL “5-star” and CLC “3-star” quality ratings.

The OIG issued 30 recommendations for improvement:

(1) Quality, Safety, and Value

• Peer review process

• Utilization management process

• Root cause analysis

• Annual patient safety report

(2) Medical Staff Privileging

• Professional practice evaluations

(3) Environment of Care

• Environmental cleanliness and safety

(4) Medication Management

• Controlled substances inspectors’ appointments

• Controlled substances inspections

• Medication override process

(5) Mental Health

• Military Sexual Trauma training

(6) Geriatric Care

• Patient/caregiver education

• Medication reconciliation

(7) Women’s Health

• Women Veterans Health Committee processes

• Cervical cancer data tracking

• Abnormal results notification

(8) High-Risk Processes

• 24-hour operations waiver

• Staffing and call schedules

• Services, equipment, and supply availability

• Patient flow metrics

• Directional signage

• Psychiatric intervention room