Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-03985-181 | Healthcare Inspection - Evaluation of the Veterans Health Administration Veterans Crisis Line | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health implement an automated transcription function for callers’ phone numbers in the Veterans Crisis Line call documentation recording system.
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2 We recommended that the Under Secretary for Health ensure that Veterans Crisis Line policies and procedures, staff education, Information Technology support, and monitoring are in place for audio call recording.
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3 We recommended that the Under Secretary for Health implement a Veterans Crisis Line governance structure that ensures cooperation and collaboration between VHA Member Services and the Office of Suicide Prevention.
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4 We recommended that the Under Secretary for Health develop clear guidelines that delineate clinical and administrative decision-making, assuring that clinical staff make decisions directly affecting clinical care of veterans in accordance with sound clinical practice.
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5 We recommended that the Under Secretary for Health ensure processes are in place for routinely reviewing backup center data, establish wait-time targets for call queuing and rollover, and ensure plans are in place for corrective action when wait-time targets are exceeded.
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6 We recommended that the Under Secretary for Health ensure processes are in place to require contracted backup centers to have the same standards as the Veterans Crisis Line related to call queuing and wait-time targets.
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7 We recommended that the Under Secretary for Health ensure that VHA Member Services leadership, Veterans Crisis Line leadership, VHA Contracting Officers, and Contracting Officer Representatives implement the quality control plan and conduct ongoing oversight to ensure contractor accountability in accordance with their roles as specified in the contract with backup call centers.
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8 We recommended that the Under Secretary for Health ensure that training is provided to Veterans Crisis Line quality management staff in the skills needed to provide leadership to promote quality and safety of care.
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9 We recommended that the Under Secretary for Health ensure the development of structured oversight processes for tracking, trending, and reporting of clinical quality performance measures.
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10 We recommended that the Under Secretary for Health ensure processes for Veterans Crisis Line quality management staff to collect and review adverse outcomes so that established cohorts of severe adverse outcomes are analyzed.
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11 We recommended that the Under Secretary for Health direct the Veterans Health Administration Assistant Deputy Under Secretary for Health for Quality, Safety, and Value to review existing Veterans Crisis Line policies and determine whether the policies incorporate the appropriate Veterans Health Administration policies for veteran safety and risk management, and if not, establish appropriate action plans.
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12 We recommended that the Under Secretary for Health ensure that Veterans Crisis Line quality management staff incorporate call audio recording into quality management data analysis.
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13 We recommended that the Under Secretary for Health ensure that processes are in place to analyze performance and quality data from the Atlanta Call Center separately from the Canandaigua Call Center data.
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14 We recommended that the Under Secretary for Health ensure that quality assurance monitoring policies and procedures are in place and consistent for both Social Service Assistants and responders.
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15 We recommended that the Under Secretary for Health ensure that supervisors certify Social Service Assistant training prior to engaging in independent assistance with rescues.
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16 We recommended that the Under Secretary for Health ensure a process is in place to establish, maintain, distribute, and educate staff on all Veterans Crisis Line policies and directives that includes verifying the use of current versions when policies and directives are modified.
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| 16-00547-156 | Clinical Assessment Program Review of the VA Portland Health Care System, Portland, Oregon | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers ensure completion of at least 75 percent of all required inpatient utilization management reviews and that facility managers monitor compliance.
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2 We recommended that facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.
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3 We recommended that facility managers ensure rolling equipment and exam table bases in patient care areas are clean and monitor compliance.
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4 We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
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5 We recommended that for patients transferred out of the facility, providers consistently include date and time of transfer in transfer documentation and that facility managers monitor compliance.
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6 We recommended that providers include all required elements in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.
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7 We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.
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8 We recommended that clinical managers ensure clinical employees who perform or assist with moderate sedation procedures have current Talent Management System training for the provision of moderate sedation care, ensure the training is documented, and monitor compliance.
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9 We recommended that the facility revise the policy on correct surgery and invasive procedures to include all elements of the timeout checklist required by Veterans Health Administration Directive 1039.
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10 We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
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11 We recommended that facility managers ensure the Community Nursing Home Review Team completes timely annual reviews and monitor compliance.
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12 We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitor compliance.
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13 We recommended that facility managers ensure all employees assigned to high-risk areas receive additional Prevention and Management of Disruptive Behavior training as required within 90 days of hire and that the training is documented in employee training records.
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14 We recommended that all members of the facility nursing expert panel receive the required training prior to the next annual staffing plan reassessment.
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| 16-00554-148 | Clinical Assessment Program Review of the Southern Arizona VA Health Care System, Tucson, Arizona | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Facility Director ensure that the Quality, Safety, and Value Executive Committee routinely reviews aggregated data and documents the reviews.
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2 We recommended that facility clinical managers ensure an interdisciplinary group reviews utilization management data and that facility managers monitor compliance.
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3 We recommended that facility managers ensure medical (biohazardous) waste stored for pick-up is secured and monitor compliance.
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4 We recommended that hemodialysis unit employees secure chemicals when not in use and that the hemodialysis unit manager monitors compliance.
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5 We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
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6 We recommended that for employees actively involved in the anticoagulant program, clinical managers complete competency assessments annually and that facility managers monitor compliance.
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7 We recommended that for patients transferred out of the facility, providers document sending or communicating to the accepting facility available history; observations, signs, symptoms, and preliminary diagnoses; and results of diagnostic studies and tests and that facility managers monitor compliance.
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8 We recommended that providers notify patients of changes in who is performing the moderate sedation procedure and document this in the electronic health record and that facility managers monitor compliance.
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9 We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
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10 We recommended that the facility ensure integration of the Community Nursing Home Program into its quality improvement program.
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11 We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews and monitor compliance.
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12 We recommended that facility managers ensure social workers conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitor compliance.
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13 We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
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14 We recommended that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that facility managers monitor compliance.
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| 16-00553-135 | Clinical Assessment Program Review of the Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
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2 We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
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3 We recommended that the Patient Safety Manager enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
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4 We recommended that facility managers ensure that wheelchairs are free of tape and clean and monitor compliance.
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5 We recommended that facility managers ensure clinicians obtain all required laboratory tests prior to initiating warfarin.
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6 We recommended that providers consistently complete transfer documentation for patients transferred out of the facility prior to or within a few hours after the transfer and that facility managers monitor compliance.
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7 We recommended that for patients transferred out of the facility, providers consistently include documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, and identification of transferring and receiving provider or designee and that facility managers monitor compliance.
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8 We recommended that facility managers ensure transfer notes written by acceptable designees contain attending physician countersignature and that facility managers monitor compliance.
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9 We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
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10 We recommended that facility managers ensure that for emergent transfers, provider transfer notes include patient stability for transfer and monitor compliance.
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11 We recommended that facility managers ensure the Community Nursing Home Oversight Committee meets at least quarterly and includes representation by all required clinical disciplines.
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12 We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitor compliance.
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13 We recommended that facility managers ensure that employees complete annual onsite inspections as required by local policy.
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14 We recommended that facility managers ensure all employees receive training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
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15 We recommended that domiciliary employees perform and document contraband inspections, rounds of all public spaces, and resident room inspections for unsecured medications and that domiciliary managers monitor compliance.
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16 We recommended that domiciliary employees perform and document hourly safety and security rounds and that domiciliary managers monitor compliance.
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| 14-02890-168 | Healthcare Inspection – Improper Consult and Appointment Management Practices, False Documentation, and Document Scanning Errors, Charlie Norwood VA Medical Center, Augusta, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Interim Under Secretary for Health ensure that all Veterans Health Administration medical facilities using the DocManager™ system certify their use of the appropriate software settings.
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2 We recommended that the Veterans Integrated Service Network Director review the circumstances surrounding improperly completed Non-VA Care Coordination and urology consults and confer with appropriate VA offices to determine the need for administrative action, if any.
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3 We recommended that the Veterans Integrated Service Network Director review the circumstances surrounding managers¿ failures to promptly evaluate the scope and breadth of the improperly completed urology consults when first learning of the issue in February 2013 and confer with appropriate VA offices to determine the need for administrative action, if any.
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4 We recommended that the Facility Director take actions to clinically evaluate the improperly completed urology consults, ensure follow-up care for those patients still requiring services, and follow Veterans Health Administration guidelines for disclosure of adverse events, if needed.
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5 We recommended that the Facility Director continue to monitor the status of the improperly completed Non-VA Care Coordination consults and assure continued care, as needed.
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6 We recommended that the Facility Director ensure that all clinic schedulers are trained on correct scheduling practices.
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| 16-00621-175 | Healthcare Inspection – Consult Delays and Management Concerns, VA Montana Healthcare System, Fort Harrison, Montana | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that the care of the potentially harmed patients be reviewed by an external (non-system) source.
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2 We recommended that the System Director confer with the Office of Chief Counsel as necessary regarding the potentially harmed patients for possible institutional disclosure, and take action as appropriate.
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3 We recommended that the System Director continue efforts to improve consult timeliness and address factors that contribute to delays.
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| 16-00551-128 | Clinical Assessment Program Review of the VA Caribbean Healthcare System, San Juan, Puerto Rico | Comprehensive Healthcare Inspection Program | ||
1 We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
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2 We recommended that facility managers ensure information technology network room doors at the facility and the St. Croix community based outpatient clinic are secured.
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3 We recommended that the facility repair ceiling leaks and replace stained and/or missing ceiling tiles on the locked mental health unit, in the ambulatory surgery waiting area, at the entrance of the Blind
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4 We recommended that facility managers ensure patient nourishment refrigerators on the medicine/oncology and locked mental health units are clean and do not contain unlabeled food items and monitor compliance.
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5 We recommended that clinicians consistently obtain all required baseline laboratory tests prior to initiating warfarin and that facility managers monitor compliance.
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6 We recommended that clinicians ensure patients newly prescribed warfarin have an international normalized ratio measurement taken within 7 days of warfarin initiation and that facility managers monitor compliance.
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7 We recommended that for patientstransferred out of the facility, providers consistently include documentation of patient or surrogate informed consent.
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8 We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
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9 We recommended that for patients transferred out of the facility, sending nurses document nurse-to-nurse communication with the receiving facility.
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10 We recommended that the facility implement an Employee Threat Assessment Team.
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11 We recommended that facility managersensure all employees receive Level I training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
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12 We recommended that providers complete diagnostic evaluations for patients with positive post-traumatic stress disorder screens within 30 days of referral.
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| 16-00550-145 | Clinical Assessment Program Review of the Harry S. Truman Memorial Veterans’ Hospital, Columbia, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee and that facility managers monitor compliance.
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2 We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
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3 We recommended that facility managers ensure ice machines and refrigerators in patient nourishment kitchens are clean and monitor compliance.
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4 We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
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5 We recommended that the facility review designated quality assurance data for the anticoagulation management program quarterly and that facility managers monitor compliance.
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6 We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications and obtain required laboratory tests during warfarin treatment at the frequency required by local policy.
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7 We recommended that the laboratorydirector ensure employees who perform glucose testing at the point of care have annual competencies for glucometers and that facility managers monitor compliance.
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8 We recommended that clinicians take anddocument all actions required by the facility in response to test results and that clinical managers monitor compliance.
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9 We recommended that the facilityimplement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
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10 We recommended that VA Police officer,Patient Safety Manager, and Patient Advocate attendance is consistently documented at Disruptive Behavior Committee meetings.
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11 We recommended that the facility includeand test slow scan/closed circuit televisions, computer-based panic alarm systems, and electronic personal panic alarms in accordance with the local physical security assessment.
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12 We recommended that facility managersensure all employees receive Level 1 training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
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13 We recommended that Cardiopulmonary Resuscitation Committee code reviews include screening for clinical issues prior to code that may have contributed to the occurrence of the code.
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| 16-00557-134 | Clinical Assessment Program Review of the Boise VA Medical Center, Boise, Idaho | Comprehensive Healthcare Inspection Program | ||
1 We recommended that Environment of Care Committee meeting minutes consistently include discussion and analysis of environment of care rounds deficiencies.
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2 We recommended that the facility revise the Ensuring Correct Surgery and Invasive Procedures policy to include all elements of the timeout checklist required by the Veterans Health Administration.
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3 We recommended that facility managers ensure the Community Nursing Home Oversight Committee meets at least quarterly and includes representation by all required disciplines.
Closure Date:
4 We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews including the analysis of the latest state survey and monitor compliance.
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5 We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitor compliance.
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| 16-03805-20 | Combined Assessment Program Summary Report – Evaluation of Inpatient Flow in Veterans Health Administration Facilities | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities revise discharge policies to include encouraging physicians to schedule discharges early in the day.
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2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities develop or revise policies addressing overflow patients in temporary bed locations and include priority placement for inpatient beds given to patients in temporary bed locations, upholding standard of care while patients are in temporary bed locations, medication administration, and meal provision.
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3 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when resident physicians complete discharge notes or instructions, supervising physicians co-sign the residents’ notes.
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15039