Comprehensive Healthcare Inspection of the VA Caribbean Healthcare System in San Juan, Puerto Rico

Report Information

Issue Date
Report Number
21-00270-04
VISN
8
State
Puerto Rico
Virgin Islands
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Care Coordination
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
10
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 VA Caribbean Healthcare System, which includes the San Juan VA Medical Center in Puerto Rico and multiple outpatient clinics in Puerto Rico and the U.S. Virgin Islands. The inspection covers key processes associated with promoting quality care. For this inspection, the areas of focus were Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior. When the team conducted this inspection, the healthcare system’s leaders had worked together in their positions for less than one month. However, they had worked together in other capacities for over two years. Employee survey results highlighted opportunities to improve staff feelings of moral distress. Patient experience survey results identified opportunities for improvement in specialty care settings. Review of the facility’s accreditation findings, sentinel events, and disclosures identified concerns with the system’s completion of institutional disclosures as well as the actions taken following serious adverse events. The executive leaders spoke knowledgeably within their scope of responsibilities about VHA data and factors contributing to poorly performing quality and efficiency measures. The OIG issued 10 recommendations for improvement in four areas: (1) Leadership and Organizational Risks • Institutional disclosures • Root cause analyses (2) Quality, Safety, and Value • Surgical work group meeting attendance (3) Registered Nurse Credentialing • Primary source verification (4) Care Coordination • Active medication list transmission • Nurse-to-nurse communication (5) High-Risk Processes • Disruptive behavior committee meeting attendance • Patient notification of Orders of Behavioral Restriction • Workplace Behavioral Risk Assessment • 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 Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct institutional disclosures for all applicable sentinel events.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Director evaluates and determines any additional reasons for noncompliance and ensures root cause analyses have actions and associated outcome measures.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Director evaluates and determines any additional reasons for noncompliance and makes certain that core members regularly attend the Surgical Workgroup meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that transferring physicians or the assigned designees send active medication lists to the receiving facilities during inter-facility transfers.
No. 6
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 nurse-to-nurse communication occurs between sending and receiving facilities.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.

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 makes certain the Disruptive Behavior Committee documents patient notification of Orders of Behavioral Restriction in the Disruptive Behavior Reporting System.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Director evaluates and determines any additional reasons for noncompliance and ensures the required interdisciplinary team conducts a Workplace Behavioral Risk Assessment each fiscal year.
No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.