Comprehensive Healthcare Inspection of the Central Alabama Veterans Health Care System in Montgomery

Report Information

Issue Date
Report Number
20-00131-243
VISN
7
State
Alabama
Georgia
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
30
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 Central Alabama Veterans Health Care System and multiple outpatient clinics in Alabama and Georgia. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection focused on 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 leadership team had vacancies in four of the five key positions. The director, associate director for patient care services, and associate director roles had been vacant for at least six months; the chief of staff position had been vacant for two years. The Deputy Director was the only permanently-assigned leader. Employee satisfaction and patient experience survey scores were generally lower than VHA averages. Executive leaders were generally knowledgeable about facility Strategic Analytics for Improvement and Learning (SAIL) measures, but lacked understanding of Community Living Center SAIL measures. The OIG issued 30 recommendations for improvement in eight areas: (1) Quality, Safety, and Value • Peer review processes • Utilization management processes • Root cause analysis processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit reviews (3) Environment of Care • Environmental cleanliness (4) Medication Management • Behavior risk assessment • Concurrent therapy • Urine drug testing • Informed consent • Patient follow-up • Pain committee (5) Mental Health • Patient follow-up • Staff training (6) Care Coordination • Goals of care conversations (7) Women’s Health • Women Veterans Health Committee • Quality data monitoring (8) High-Risk Processes • Annual risk analysis • Airflow testing • 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 Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that final peer reviews are completed within 120 calendar days from the date a peer review is required, and any necessary extensions are approved in writing by the System Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff determines the reasons for noncompliance and makes certain that the Interdisciplinary Peer Review Panel provides quarterly analysis summaries to the Medical Executive Council.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager includes all required elements in root cause analyses and properly documents root cause analyses in the VHA Patient Safety Information System.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager submits each root cause analysis to the National Center for Patient Safety within the required time frame.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Patient Safety Manager or designee provides feedback to staff who submit patient adverse event reports that result in root cause analysis actions.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete focused and ongoing professional practice evaluations of licensed independent practitioners.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service- or section-specific ongoing professional practice evaluation data.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director evaluates and determines any additional reasons for noncompliance and makes certain the licensed healthcare professional’s first- or second-line supervisor completes and signs the exit review form within seven calendar days of the professional’s departure from the healthcare system.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that healthcare system managers maintain a safe and clean environment by identifying and resolving environmental deficiencies found during environment of care rounds.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors on patients prior to initiating long-term opioid therapy.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers document justification for prescribing opioids and benzodiazepines concurrently.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing for patients on long-term opioid therapy.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers follow up with patients within the required time frame after initiating long-term opioid therapy.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers’ follow-up with patients receiving long-term opioid therapy includes an assessment of adherence to the pain management plan of care.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers’ follow-up with patients receiving long-term opioid therapy includes an assessment of intervention effectiveness.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Pain Management Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct four follow-up appointments within the required time frame for patients flagged as high risk for suicide.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director evaluates and determines any additional reasons for noncompliance and ensures clinical and nonclinical staff complete annual suicide prevention refresher training.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete and document goals of care conversations prior to hospice referrals.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that all required members consistently attend Women Veterans Health Committee meetings and the committee reports to executive leaders.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that healthcare system staff collect and track the required women veterans quality assurance data.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief reports the annual risk analysis to the Veteran Integrated Service Network Sterile Processing Services Management Board.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Deputy Director evaluates and determines any additional reasons for noncompliance and ensures that the Chief, Engineering Services conducts annual airflow testing in all areas where reusable medical equipment is reprocessed or stored.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that commercial airflow directional devices are used in areas where reusable medical equipment is reprocessed and stored.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Reusable Medical Equipment Coordinator completes competency assessments for all staff reprocessing reusable medical equipment.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services staff receive monthly continuing education.