Comprehensive Healthcare Inspection of the Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana

Report Information

Issue Date
Report Number
19-00046-60
VISN
16
State
Louisiana
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Major Management Challenges
Healthcare Services
Recommendations
17
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 delivered at the Southeast Louisiana Veterans Health Care System, covering leadership and organizational risks and key processes associated with promoting quality care. 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 leadership team appeared relatively stable, having worked together for seven months at the time of the inspection. Selected survey scores indicated that employees and patients were generally satisfied. Review of accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. The leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics, but should continue to take actions to improve performance of measures contributing to the SAIL “3-star” quality rating. The new CLC had not been assigned a quality star rating as of December 31, 2018. The OIG issued 17 recommendations for improvement: (1) Quality, Safety, and Value • Review of utilization management data • Resuscitation episode reviews • Code responder training (2) Medical Staff Privileging • Ongoing and focused professional practice evaluation processes (3) Environment of Care • Medication safety (4) Military Sexual Trauma (MST) Follow-up and Staff Training • MST mandatory training (5) Antidepressant Use among the Elderly • Patient/caregiver education • Medication reconciliation (6) Abnormal Cervical Pathology Results Notification and Follow-up • Full-time women veterans program manager • Women Veterans Health Committee membership and reporting process • Cervical cancer screening data tracking • Patient notification of abnormal results (7) Emergency Departments and Urgent Care Center Operations • Emergency department backup call schedule

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 makes certain that required representatives participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that the Cardiopulmonary Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and the reviews include required elements and monitors committee’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms clinical staff responding to resuscitation events have basic or advanced cardiac life support certification and monitors clinical staff compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures service chiefs include defined time frames in focused professional practice evaluations and monitors service chiefs’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that service chiefs ensure that focused professional practice evaluations are completed by providers with similar training and privileges and monitors service chiefs’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain service chiefs include service-specific criteria for ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that service chiefs ensure that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors service chiefs’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that service chiefs clearly define and share in advance with providers the time frame, expectations, and outcomes for focused professional practice evaluations for cause that do not limit providers’ ability to practice independently for more than 30 days and monitors service chiefs’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director for Patient Care Services ensures that nursing staff label multi-dose medication vials with an expiration date upon opening and monitors staff compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about 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 maintain accurate medication information in patients’ electronic health records and monitors clinicians’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the facility has a full-time women veterans program manager.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that the Women Veterans Health Committee includes required core members and reports to a clinical executive level committee and monitors the committee’s compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that program managers implement a process to track and monitor cervical cancer screenings and follow-up care and monitors program managers’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that ordering providers communicate abnormal results to patients 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 ensures the chief of Social Work maintains a backup call schedule for emergency department social workers.