Comprehensive Healthcare Inspection of the VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts

Report Information

Issue Date
Report Number
19-00038-63
VISN
1
State
Massachusetts
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
30
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
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

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 that peer reviewers consistently use at least one of the aspects of care when conducting peer reviews and monitors reviewers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that managers consistently implement, and document completion of improvement actions recommended by the Peer Review Committee and monitors the managers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that peer review data is reported quarterly to the Executive Committee of the Medical Staff and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures utilization management staff complete and document acute inpatient and observations stay reviews as required and monitors staff compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that Physician Utilization Management Advisor(s) consistently complete reviews and document their decisions in the National Utilization Management Integration database and monitors compliance.
No. 6
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the patient safety manager or designee completes the required number of root cause analyses that include the required content annually and monitors the patient safety manager’s compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the patient safety manager or designee provides an annual patient safety report to facility leaders and monitors the patient safety manager’s compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that clinical managers clearly define the criteria, time frames, and expectations with providers in advance for focused professional practice evaluations and monitors the clinical managers’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that the Executive Committee of the Medical Staff reviews and evaluates the focused and ongoing professional practice evaluation results and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director ensures that patients areas are clean and that action is taken to minimize or eliminate identified safety risks in the environment and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that controlled substances inspectors are appointed in writing with a term not to exceed three years and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that monthly reconciliation of one day’s dispensing from pharmacy to every automated dispensing cabinet and one day’s return of stock to pharmacy from every automated dispensing cabinet is performed during controlled substances inspections and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that controlled substances inspectors verify there is evidence of a written or electronic controlled substances order for five randomly selected dispensing activities during monthly inspections and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the development and implementation of a policy for automated dispensing cabinet medication overrides and reviews of these reports and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that primary care and mental health providers complete mandatory military sexual trauma training within the required time frame and monitors providers’ compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff certifies that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and evaluate understanding when education is provided, and monitors clinicians’ compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures clinicians complete and document medication reconciliation as required and monitors the clinicians’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the Women Veterans Health Committee meets at least quarterly, includes required core members, and reports to the appropriate executive committee and monitors the committee’s compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures tracking and monitoring of cervical cancer data and monitors compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that ordering providers communicate abnormal results to patients 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 makes certain that the facility has an approved waiver from the national director of Emergency Medicine if the urgent care center continues to operate 24 hours a day, seven days a week.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the urgent care center is staffed with at least two registered nurses physically present during all hours of operation and monitors compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that a backup call schedule is maintained for urgent care providers and monitors compliance.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that support services necessary to care for patients are readily available to the urgent care center during all hours of operation and monitors compliance.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that social work services are available to the urgent care center during all hours of operation, and monitors compliance.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that action plans are developed and implemented for underperforming patient flow metrics in the urgent care center and monitors compliance.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that appropriate signage is in place to direct patients to the urgent care center and monitors compliance.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that at least one room is identified as the psychiatric intervention room in the urgent care center and monitors compliance.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that equipment and supplies necessary to care for patients are readily available at all times in the urgent care center and monitors compliance.