Comprehensive Healthcare Inspection of the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana

Report Information

Issue Date
Report Number
19-00012-51
VISN
10
State
Indiana
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Patient Safety
Supplies and Equipment
Major Management Challenges
Healthcare Services
Recommendations
13
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 Richard L. Roudebush VA Medical Center, covering leadership and organizational risks and key processes associated with promoting quality care. For this inspection, areas of focus included 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 leadership team was relatively new, having worked together for about four months as of the week of the OIG’s visit. Selected survey scores related to employee satisfaction and patient experience were generally better than the VHA average but revealed some opportunities for improvement. The OIG reviewed accreditation agency findings, sentinel events, adverse patient event disclosures, patient safety indicator data, and identified organizational risk factors. Leaders were generally knowledgeable about selected Strategic Analytics for Improvement and Learning metrics but should continue to act to sustain and improve performance of measures contributing to the facility’s “3-star” quality rating. The OIG issued 13 recommendations for improvement: (1) Quality, Safety, and Value • Peer Review Committee summary reports • Interdisciplinary review of utilization management data • Review of relevant literature in root cause analyses • Resuscitative episode reviews • Implementation and monitoring of corrective actions (2) Medical Staff Privileging • Focused professional practice evaluation processes (3) Environment of Care • Wheelchair maintenance (4) Medication Management: Controlled Substances Inspections • Controlled substances inspection report reviews • Signatures for controlled substances waste • Override report reviews (5) Geriatric Care: Antidepressant Use among Elderly • Patient/caregiver education • Medication reconciliation (6) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership composition

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 the Executive Committee of the Medical Staff reviews quarterly Peer Review Committee summary reports with trends and analysis of aggregate data and monitors the committee’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes sure the patient safety manager includes a review of relevant literature in the root cause analysis and monitors the patient safety manager’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the Cardiopulmonary Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and monitors the committee’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that clinical managers implement corrective actions and monitor for effectiveness when problems or opportunities for improvement are identified and monitors the clinical managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that clinical service chiefs clearly define and share in advance the expectations and outcomes for focused professional practice evaluations for cause that do not restrict the providers’ ability to practice independently for more than 30 days with providers and monitors the clinical service chiefs’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director assures managers remove damaged wheelchairs from service and send them for repair or replacement and monitors managers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the facility quality manager ensures the Clinical and Performance Board reviews the monthly and quarterly controlled substance inspection program reports at least quarterly and monitors the quality manager’s compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the controlled substances inspectors verify documentation for two signatures for any waste of partial doses of controlled substances and monitors inspectors’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that a pharmacist reviews the Omnicell® override report for appropriateness and frequency as required and monitors the pharmacist’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures clinicians review and reconcile medications and monitors the clinicians’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.