Comprehensive Healthcare Inspection Summary Report for Fiscal Year 2019

Report Information

Issue Date
Report Number
20-01994-18
VISN
State
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
National Healthcare Review
Report Topic
Patient Safety
Medical Staff Privileging Credentialing
Military Sexual Trauma
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
32
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered by Veterans Health Administration facilities. The report covers key processes that are associated with promoting quality care, and focuses on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma (MST) 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: Operations and Management of Emergency Departments and Urgent Care Centers. The Office of Inspector General (OIG) noted that 88 percent of facility leaders were assigned permanently at the 43 VA facilities visited in fiscal year 2019. These facility leaders generally appeared engaged in quality activities, felt supported by network leaders, were aware of employee/patient satisfaction improvement efforts, and actively addressed recommendations for improvement. However, the OIG found opportunities for some facilities to improve their Strategic Analytics for Improvement and Learning ratings. The OIG issued 32 recommendations for improvement across eight areas: (1) Quality, Safety, and Value • Peer review processes • Cardiopulmonary resuscitation committee processes (2) Medical Staff Privileging • Focused and ongoing professional practice evaluations (3) Environment of Care • Emergency resource and asset inventory review (4) Medication Management • Controlled substances inspection report review • Limitations to perform balance adjustments • Monthly physical controlled substances inspections • Override report review (5) Mental Health • MST issues, services, and initiatives communicated to leaders • Mandatory MST training (6) Geriatric Care • Patient and/or caregiver education • Medication reconciliation (7) Women’s Health • Committee membership and activities • Cervical cancer screening data tracking (8) High-Risk Processes • Operating hours, staffing, support services, and directional signage

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 Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility-level senior leaders, ensures that summaries of the peer review committees’ work are reviewed quarterly by medical executive committees.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that all applicable deaths within 24 hours of admission are peer reviewed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that cardiopulmonary resuscitation committees review each resuscitative episode under the facilities’ responsibility and include required elements in reviews.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures focused professional practice evaluation criteria are defined in advance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures service chiefs include the minimum specialty criteria for focused professional practice evaluations of gastroenterology, pathology, nuclear medicine, and radiation oncology practitioners.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures executive committees of the medical staff document the decision to recommend continuing licensed independent practitioners’ privileges based on ongoing professional practice evaluation results.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that service chiefs’ privileging determinations are based, in part, on ongoing professional practice evaluation activities.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that ongoing professional practice evaluations use assessments by providers with similar training and privileges.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures facility clinical managers clearly define and share in advance the expectations, outcomes, and time frames for focused professional practice evaluations for cause with licensed independent practitioners.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that inventories of resources and assets that may be needed during an emergency are documented and reviewed annually.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that monthly and quarterly controlled substances inspection reports are reviewed at least quarterly by the facility committees responsible for quality oversight.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that electronic access for monitoring and performing controlled substances balance adjustments is limited to appropriate staff.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors complete monthly physical inspections of controlled substances storage areas on the day initiated.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify controlled substance orders for five randomly selected dispensing activities.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify that drugs listed on the “Destructions File Holding Report” are secured and documented and that there is a corresponding sealed evidence bag for each medication during monthly inspections.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify the inventory count for prescription pads on the day of monthly pharmacy inspections.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify written controlled substances prescriptions during monthly area inspections.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify pharmacy vault inventory at the required frequency.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors complete emergency drug cache inspections that include checks for lock tampering and verification of lock numbers.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinical managers implement processes for reviewing automated drug dispensing cabinet override reports.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures military sexual trauma coordinators establish and monitor related training.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures military sexual trauma coordinators communicate related issues, services, and initiatives to facility leaders.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures mental health and primary care providers complete mandatory military sexual trauma training within the required time frame.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinicians provide and document education on newly prescribed medications and assess patient/caregiver understanding of the information provided.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinicians review and reconcile patients’ medications and maintain and communicate accurate medication information in electronic health records.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure that women veterans health committees include required core members, meet at least quarterly, and report to leadership.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinical managers implement quality assurance processes that include tracking of cervical cancer screening notification and follow-up care.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that urgent care centers operating 24 hours a day, 7 days a week have an approved waiver from the National Director of Emergency Medicine.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that emergency departments and urgent care centers are staffed with a minimum of two registered nurses during all hours of operation.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure clinical managers maintain a backup call schedule for emergency department and urgent care center providers.
No. 31
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that support services, including social work, are available to emergency departments and urgent care centers during all hours of operation.
No. 32
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities use appropriate signage to direct patients to emergency departments and urgent care centers.