Recommendations

We recommended that the facility ensure the designated quality, safety, and value committee meets quarterly and is chaired or co-chaired by the Facility Director.

We recommended that the facility revise the policy/by-laws to specify a frequency for clinical managers to review practitioners’ Ongoing Professional Practice Evaluation data every 6 months.

We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data and that facility managers monitor compliance.

We recommended that facility clinical managers ensure an interdisciplinary group reviews utilization management data and that facility managers monitor compliance.

We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.

We recommended that the facility consistently evaluate actions for effectiveness in the Clinical Executive Committee and Performance Improvement Board and that facility managers monitor compliance.

We recommended that facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.

We recommended that facility managers ensure horizontal surfaces, ventilation grills, and floors in patient care areas are clean and monitor compliance.

We recommended that facility managers ensure ice machines and refrigerators in patient nourishment kitchens are clean and monitor compliance.

We recommended that facility managers ensure the standard operating procedure for the retrograde cholangiopancreatography endoscope is consistent with the manufacturer’s instructions for use.

We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive competencies at orientation and annually for the types of reusable medical equipment they reprocess.

We recommended that the facility revise the policy for anticoagulation management to include addressing no shows and patient noncompliance and minimizing loss to follow-up.

We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.

We recommended that clinical managers complete semiannual competency assessments for employees actively involved in the anticoagulant program and that facility managers monitor compliance.

We recommended that the facility collect and report data on patient transfers out of the facility.

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, identification of transferring and receiving provider or designee, and details of the reason for transfer or proposed level of care needed in transfer documentation and that facility managers monitor compliance.

We recommended that facility managers ensure that for emergent transfers, provider transfer notes include patient stability for transfer and monitor compliance.

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.

We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.

We recommended that the facility report and trend the use of reversal agents in moderate sedation cases and process adverse events/complications in a similar manner as operating room anesthesia adverse events and that facility managers monitor compliance.

We recommended that the VA Police Officer, Patient Safety Manager and/or Risk Manager, and Patient Advocate consistently attend Disruptive Behavior Committee meetings.

We recommended that the facility collect and analyze data from disruptive or violent behavior incidents.

We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags.

We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.

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.

We recommended that all doors on the Domiciliary Care for Homeless Veterans Program unit other than the main point of entry be locked and alarmed.

We recommended that the facility fully implement the nurse staffing methodology and conduct annual reassessments.