Comprehensive Healthcare Inspection of Veterans Integrated Service Network 1: VA New England Healthcare System, Bedford, Massachusetts

Report Information

Issue Date
Report Number
19-06866-68
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
Medical Staff Privileging Credentialing
Major Management Challenges
Healthcare Services
Recommendations
12
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Comprehensive Healthcare Inspection Program provides a focused evaluation of the leadership performance and oversight by the Veterans Integrated Service Network (VISN) 1: VA New England Healthcare System, covering leadership and 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; and Medication Management: Controlled Substances Inspections. The OIG conducted this unannounced visit while concurrent inspections of the following VISN 1 facilities were also performed: VA Central Western Massachusetts Healthcare System, Leeds, MA; Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; and Manchester VA Medical Center, NH. The VISN 1 leadership team appeared relatively stable. Employee satisfaction scores were generally better than VHA averages. However, opportunities appear to exist for the network director to improve employee satisfaction; the deputy network director to model servant leadership; and the network director, deputy network director, and chief medical officer to reduce employee moral distress at work. Patient experience results were above VHA averages. VISN 1 leaders supported efforts to provide accessible and inclusive care for women veterans, and access metrics and clinician vacancies did not identify any significant organizational risks. Leaders appeared knowledgeable about efforts taken to reduce veteran suicide as well as selected Strategic Analytics for Improvement and Learning and community living center performance metrics; but should continue to support facility actions to improve care provided throughout VISN 1. The OIG issued 12 recommendations for improvement: (1) Quality, Safety, and Value • Acute inpatient stay reviews • Utilization management data reviews • Minimum of eight root cause analyses (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (3) Environment of Care • VISN comprehensive environment of care program • VISN emergency management committee processes (4) Medication Management: Controlled Substances Inspections • Quarterly trend report reviews

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 network director ensures that staff at each Veterans Integrated Service Network facility perform the required acute inpatient stay reviews and monitors staff compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The quality management officer confirms that an interdisciplinary group at each facility reviews utilization management data and monitors the group’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The quality management officer makes certain that staff at each facility annually complete a minimum of eight root cause analyses and monitors staff compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief medical officer ensures that facility clinical managers define criteria in advance for licensed independent practitioners’ focused professional practice evaluations and monitors clinical managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief medical officer confirms that facility clinical managers include service-specific criteria in ongoing professional practice evaluations for licensed independent practitioners and monitors clinical managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief medical officer confirms that ongoing professional practice evaluation results are based on evaluation by another provider with similar training and privileges and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief medical officer verifies that facilities’ executive committee of the medical staff document the decision to recommend continuing privileges for licensed independent practitioners based on ongoing professional practice evaluation results and monitors committees’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief medical officer makes certain that facility clinical managers clearly define and share in advance the expectations, outcomes, and time frames with licensed independent practitioners for focused professional practice evaluations for cause and monitors clinical managers’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The deputy network director ensures a written policy establishes and maintains a Veterans Integrated Service Network-level comprehensive environment of care program.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The deputy network director makes certain that the emergency management committee conducts an annual review of the emergency operations plan, continuity of operations plan, and hazards vulnerability analysis and monitors the committee’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The deputy network director makes certain that the emergency management committee conducts, documents, and sends an annual review of the collective Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement to leadership for review and approval and monitors the committee’s compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The quality management officer reviews Veterans Integrated Service Network facilities’ controlled substances inspection quarterly trend reports.