Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center in Alabama

Report Information

Issue Date
Report Number
20-00130-194
VISN
7
State
Alabama
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
14
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Tuscaloosa VA Medical Center and one outpatient clinic in Alabama. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The executive leaders worked together for four months; however, the Director and the Associate Director for Patient Care Services had worked together since 2015. Survey results revealed opportunities for the Associate Director for Patient Care Services to improve employee satisfaction. Survey data indicated that patients were generally satisfied with their care experiences, but there were opportunities to improve appointment wait times. Review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. However, the OIG identified concerns regarding peer review and patient safety programs. The executive leaders were extremely knowledgeable within their scope of responsibilities about Strategic Analytics for Improvement and Learning data and should continue to act to sustain and improve performance. The OIG issued 14 recommendations for improvement in five areas: (1) Environment of Care • Emergency egress accessible • Wheelchair maintenance (2) Mental Health • Community outreach • Patient follow-up (3) Care Coordination • Goals of care conversations • Multidisciplinary committee representatives and activities (4) Women’s Health • Staffing requirements (5) High-Risk Processes • Equipment inventory file • Instrument tracking system • Annual risk analysis • Environmental cleanliness • Sterile area climate control • Staff training

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 Associate Director determines the reason(s) for noncompliance and ensures egresses are free of blockages.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director determines the reason(s) for noncompliance and ensures damaged wheelchairs are repaired or removed from service.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and makes certain that the Suicide Prevention Coordinator ensures completion and documentation of at least five outreach activities each month.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that clinicians conduct four follow-up appointments within the required time frame.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that providers document all required elements of goals of care conversations.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines reason(s) for noncompliance and certifies that the multidisciplinary committee responsible for life-sustaining treatment decision reviews include three or more different disciplines and at least one member from the medical center’s Ethics Consultation Service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director determines the reason(s) for noncompliance and ensures that the multidisciplinary committee reviews life-sustaining treatment plans for patients who lack decision-making capability and do not have a surrogate.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures the medical center’s Women Veterans Program Manager is free of collateral duties.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Nursing and Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that the Associate Chief Nurse of Operations maintains an accurate file of all reusable devices that includes current manufacturers’ instructions for use.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Nursing and Patient Care Services determines the reason(s) for noncompliance and makes certain that the CensiTrac® instrument tracking system is installed and operational.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Nursing and Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that the Associate Chief Nurse of Operations reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director evaluates and determines any additional reason(s) for noncompliance and ensures that Sterile Processing Services areas are cleaned as scheduled.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Nursing and Patient Care Services determines the reason(s) for noncompliance and ensures that Sterile Processing Services maintains required climate control parameters for areas where reusable medical equipment is reprocessed and stored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Nursing and Patient Care Services determines the reason(s) for noncompliance and ensures that Sterile Processing Services staff receive competency assessments for reprocessing reusable medical equipment.