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Comprehensive Healthcare Inspection of the VA Hudson Valley Health Care System in Montrose, New York

Report Information

Issue Date
Report Number
21-00298-72
VISN
2
State
New York
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
Recommendations
7
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 Hudson Valley Health Care System in Montrose, New York. The inspection covered key clinical and administrative processes that are associated with promoting quality care, focusing on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior. At the time of the review, the healthcare system’s leaders had worked together for one year, with the Director, Associate Director for Patient Care Services, and Chief of Staff serving since May 2020, December 2015, and August 2019, respectively. The Associate Director was appointed in December 2020 and also covered the open assistant director position. Employee survey scores for the healthcare system were lower than the VHA averages, although scores for most leaders were generally similar to or higher than VHA and healthcare system averages. Outpatient satisfaction survey results generally reflected higher care ratings than VHA averages. However, they also highlighted opportunities to improve patient perceptions of inpatient care, as well as outpatient providers and access to outpatient services. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors but position turnover in the Quality Management Service was noted as an area of vulnerability. Executive leaders were very knowledgeable about selected data used in Strategic Analytics for Improvement and Learning measures. The OIG issued seven recommendations for improvement in three areas: (1) Quality, Safety, and Value • Protected peer review process (2) Care Coordination • Inter-facility transfer policy and documentation • Nurse-to-nurse communication (3) High Risk Processes • 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 System Director evaluates and determines any additional reasons for noncompliance and makes certain that final peer reviews are completed within 120 calendar days or have a written extension request approved by the Director.
No. 2
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 a written policy is in place to ensure the safe, appropriate, orderly, and timely transfer of patients.
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 the referring physician includes all required elements on the VA Inter-Facility Transfer Form or facility-defined equivalent note in the patient’s electronic health record.
No. 4
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 staff send pertinent medical records to the receiving facility during inter-facility transfers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services determines any additional reasons for noncompliance and makes certain that nurse-to-nurse communication occurs between sending and receiving facilities.
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 Employee Threat Assessment Team members complete required trainings.
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 ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.