Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-00497-161 | Leadership, Clinical, and Administrative Concerns at the Charlie Norwood VA Medical Center, Augusta, Georgia | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director evaluates the quality and professionalism of Executive Leadership Team communications and takes action when indicated.
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2 The Veterans Integrated Service Network Director requires the development of, and follow-through on, corrective action plans responding to relevant findings from the National Center of Organizational Development’s 2018 site visits and reports.
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3 The Charlie Norwood VA Medical Center Director develops a process to ensure that Light Electronic Action Framework hiring requests are tracked and processed timely.
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4 The Charlie Norwood VA Medical Center Director reviews the facility’s hiring processes to identify opportunities to improve the efficiency and timeliness of hiring actions, and takes corrective action, as needed.
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5 The Charlie Norwood VA Medical Center Director ensures development and broad dissemination of a written critical care unit bed management policy that clearly states the process to be followed when an inpatient requires intensive care and a critical care unit bed is unavailable.
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6 The Charlie Norwood VA Medical Center Director ensures development and broad dissemination of a written policy regarding patient-owned medical devices and equipment that clearly outlines restrictions and acceptable uses when the patient is hospitalized.
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7 The Charlie Norwood VA Medical Center Director ensures development and broad dissemination of a standardized method for documenting and ensuring compliance with the internal hand-off communication policy.
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8 The Charlie Norwood VA Medical Center Director ensures that neurosurgery privileges are amended to include only procedures which facility infrastructure can support.
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9 The Charlie Norwood VA Medical Center Director ensures that the nurse’s failure related to the computed tomography (CT) event outlined in this report is evaluated and administrative action is taken, as indicated.
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10 The Charlie Norwood VA Medical Center Director enhances processes to document Strategic Analytics for Improvement and Learning related improvement actions.
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11 The Charlie Norwood VA Medical Center Director continues efforts to improve patient and employee satisfaction.
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12 The Charlie Norwood VA Medical Center Director ensures prompt evaluation of sentinel events, to include root cause analyses, in accordance with Veterans Health Administration requirements.
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13 The Charlie Norwood VA Medical Center Director evaluates the documentation failures related to Patient Y, and takes appropriate action, as indicated.
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14 The Charlie Norwood VA Medical Center Director ensures the development of policy addressing the appropriate method for confirming and documenting nasogastric tube placement prior to administration of medications or tube feedings, including actions that should be taken when a nasogastric tube is partially dislodged.
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15 The Charlie Norwood VA Medical Center Director requires the Associate Director for Patient and Nursing Services to ensure that all registered nurses assigned to work in critical care units promptly complete assessments for missing unit-specific competencies.
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16 The Charlie Norwood VA Medical Center Director requires the Associate Director for Patient and Nursing Services to enhance processes to ensure that nursing competency skills assessments are specific to individual duty assignments and completed in accordance with Veterans Health Administration and facility policy.
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17 The Charlie Norwood VA Medical Center Director ensures that critical care unit staffing decisions include contingencies for staff absences.
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18 The Charlie Norwood VA Medical Center Director continues efforts to recruit and hire for critical care unit and emergency department nurse vacancies, and ensure that until optimal staffing is attained, alternate methods are consistently available to meet patient care needs.
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19 The Charlie Norwood VA Medical Center Director ensures that unexcused nursing absences are managed in accordance with relevant Human Resource guidelines.
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20 The Charlie Norwood VA Medical Center Director ensures that the emergency department security system is upgraded to meet current security requirements and to provide a safe environment for patients and staff.
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21 The Charlie Norwood VA Medical Center Director continues efforts to recruit and hire for critical laboratory staff vacancies, and ensures that until optimal staffing is attained, alternate methods are consistently available that meet patient care needs.
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22 The Charlie Norwood VA Medical Center Director ensures that before policy changes are made that impact the delivery of quality patient care, broad discussion with all key stakeholders takes place and written guidance is widely disseminated.
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23 The Charlie Norwood VA Medical Center Director ensures that policies and procedures regarding the appropriate transfer of critically ill patients are developed in conjunction with key stakeholders and that the process is widely disseminated to relevant staff.
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24 The Charlie Norwood VA Medical Center Director ensures the Contracting Officer’s Representative responsible for the technical administration of the transportation contract conducts surveillance of the contractor’s performance and provides oversight of the contractual agreements.
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25 The Charlie Norwood VA Medical Center Director ensures contingency plans are in place to rapidly mobilize staff when emergency department patients’ care demands exceed the current staffing resources.
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26 The Charlie Norwood VA Medical Center Director ensures there is a signed boarder policy, which is broadly disseminated.
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27 The Veterans Integrated Service Network Director completes an assessment of the facility’s ability to assure consistent availability of services and staffing to support providers’ professional practice and the safe and timely delivery of care, and takes action as necessary.
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| 18-06508-155 | Comprehensive Healthcare Inspection of the James H. Quillen VA Medical Center, Mountain Home, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 The facility director makes certain that controlled substances inspectors complete monthly physical inventories of controlled substance storage areas on the day initiated and monitors the inspectors’ compliance.
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2 The facility director ensures that controlled substances program staff reconcile the restocking/refilling from the pharmacy to every automated dispensing cabinet for one random day during monthly controlled substances area inspections and monitors controlled substances program staff’s compliance.
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3 The facility director ensures that controlled substances program staff reconcile the return of stock from every automated dispensing cabinet to the pharmacy for one random day during monthly controlled substances area inspections and monitors controlled substances program staff’s compliance.
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4 The facility director confirms that controlled substances inspectors complete emergency drug cache inspections and monitors inspectors’ compliance.
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5 The chief of staff makes certain that clinicians provide and document patient/caregiver education specific to the newly prescribed medication and monitors clinicians’ compliance.
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| 17-05859-131 | Management of Major Medical Leases Needs Improvement | Audit | ||
1 The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics, and Construction ensure there are adequate funds available to routinely conduct planning activities, including developing requests for lease proposals, for Strategic Capital Investment Planning approved major leases while waiting for congressional authorization.
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2 The Assistant Secretary for Management and Chief Financial Officer reconsider centralizing major medical lease acquisition funding through VA’s acceptance of the completed building.
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3 The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics, and Construction obtain adequate resources to deliver leases on schedule.
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4 The Assistant Secretary for Management ensure that the prospectus cost estimates provided to Congress are accurate and the costs are allocated appropriately to comply with OMB Circular A-11 requirements.
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5 The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics, and Construction implement a comprehensive VA policy for critical decisions in the lease acquisition process establishing clear lines of authority and allowable time frames.
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6 The Deputy Under Secretary for Health for Operations and Management and the Executive Director, Office of Construction Facilities Management, ensure VA uses appropriate security measure requirements when acquiring VA major medical leases by performing Interagency Security Committee risk evaluations prior to solicitation.
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7 The Executive Director, Office of Construction Facilities Management, ensure project acquisition teams are adequately trained in performance-based acquisition.
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8 The Executive Director, Office of Construction Facilities Management, evaluate the use of consultants in the solicitation development process for Requests for Lease Proposals of major medical leases on a case-by-case basis.
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| 18-03576-158 | Deficiencies in Discharge Planning for a Mental Health Inpatient Who Transitioned to the Judicial System from a Veterans Integrated Service Network 4 Medical Facility | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director solicits an ethics consult regarding the patient’s final episode of care and treatment course including the failure to inform the patient or family of impending arrest and lack of family inclusion in decision-making.
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2 The Facility Director strengthens inpatient mental health unit processes to include the patient, family members, or surrogate in treatment and discharge planning decisions.
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3 The Facility Director evaluates the inpatient mental health unit assessment practices of patients’ decision-making capacity and voluntary admission status, and takes actions as appropriate.
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4 The Facility Director ensures that facility staff identify and document patients’ surrogates accurately.
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5 The Facility Director ensures that inpatient mental health unit discharge processes include a complete medical and psychiatric diagnostic summary to patients’ receiving mental health providers.
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6 The Facility Director develops inpatient mental health unit discharge processes that include a clinical hand-off communication to patients’ receiving mental health providers.
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7 The Facility Director ensures that a mental health treatment coordinator is assigned for patients during all episodes and levels of mental health care.
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8 The Facility Director ensures that informed consent is obtained from patients or authorized surrogates for release of information as required.
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9 The Facility Director evaluates inpatient mental health unit admission practices and develops processes in compliance with Veterans Health Administration policy regarding voluntary and involuntary admissions.
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10 The Facility Director provides guidance to clinical staff regarding access to consultative resources such as forensic mental health experts, Office of General Counsel, and Ethics Consultation Service.
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| 18-00037-154 | Review of Mental Health Clinical Pharmacists in Veterans Health Administration Facilities | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health ensures facility medical staff bylaws are consistent with Veterans Health Administration policy regarding clinical pharmacist practice as non-independent practitioners.
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2 The Under Secretary for Health ensures collaborating agreements, also referenced as collaborative practice agreements, are in place for mental health clinical pharmacists who provide outpatient collaborative medication management.
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3 The Under Secretary for Health ensures that the Veterans Health Administration Office of Mental Health and Suicide Prevention Director reviews existing Veterans Health Administration guidance and provides assistance in outlining the mental health clinical pharmacist’s responsibilities for communication with the collaborating licensed independent practitioner who has prescribing authority.
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4 The Under Secretary for Health affirms allowable clinical duties within mental health clinical pharmacists’ scopes of practice include comprehensive provisions related to mental health.
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5 The Under Secretary for Health ensures a process is in place for chiefs of mental health service to document review, recommendation, and endorsement of all outpatient mental health clinical pharmacists’ scopes of practice, regardless of whether the clinical pharmacist is aligned with the mental health service line, and monitor compliance.
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6 The Under Secretary for Health ensures the Veterans Health Administration Office of Mental Health and Suicide Prevention Director reviews and provides input into the patient referral process to mental health clinical pharmacists with consideration for ensuring that accurate diagnoses can be reliably identified by and conveyed to the mental health clinical pharmacists.
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7 The Under Secretary for Health ensures the Veterans Health Administration Office of Mental Health and Suicide Prevention Director reviews the patient referral process to mental health clinical pharmacists and provides input with consideration for clinical settings or scenarios in which a review of the clinical complexity of the referral by a licensed independent practitioner with prescribing authority would be appropriate, prior to treatment.
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8 The Under Secretary for Health ensures the Veterans Health Administration Office of Mental Health and Suicide Prevention Director establishes guidance and provides assistance in outlining when and how mental health clinical pharmacists are to refer patients to a higher level of mental health care.
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9 The Under Secretary for Health initiates a risk assessment of outpatient mental health clinical pharmacists’ practice and establish mitigation plans; and includes the Veterans Health Administration Office of Mental Health and Suicide Prevention Director in the design, implementation, and analysis processes.
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| 19-00022-153 | Delay in Diagnosis and Subsequent Suicide at a Veterans Integrated Service Network 15 Medical Facility | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health ensures that the planning and implementation of the new electronic medical record includes, (a) a fail-safe system that allows communication and tracking of test results to multiple clinical staff members who coordinate patient notification, appropriate follow-up testing and clinical management, and (b) the ability to monitor actions taken by the responsible provider(s).
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2 The Veterans Integrated Service Network 15 Medical Facility Director initiates an administrative review of the clinical care the patient received and takes action as appropriate based on the results.
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3 The Veterans Integrated Service Network 15 Medical Facility Director ensures that Patient Centered Management Module provider and patient assignments are timely, and data are validated as required by Veterans Health Administration policy.
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4 The Veterans Integrated Service Network 15 Medical Facility Director issues guidance that establishes a clearly-defined process for the designation of surrogates to include abnormal test results and consults.
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5 The Veterans Integrated Service Network 15 Medical Facility Director confirms that once issued, providers are trained on the process for designation of surrogates and monitor compliance.
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6 The Veterans Integrated Service Network 15 Medical Facility Director reviews current view alert parameters, evaluates providers’ knowledge and management of view alerts, and takes action, as necessary, to ensure and monitor compliance.
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7 The Veterans Integrated Service Network 15 Medical Facility Director evaluates communication among Patient Aligned Care Team members, including the sharing of, the timeliness of, and the response to patient secure messages, and takes action based on the evaluation.
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8 The Veterans Integrated Service Network 15 Medical Facility Director reviews processes within Primary Care related to patient notification of test results and takes action to ensure test results are communicated to patients as required by Veterans Health Administration policy.
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9 The Veterans Integrated Service Network 15 Medical Facility Director reviews Veterans Health Administration and the Veterans Integrated Service Network 15 Medical Facility policies concerning disclosure of adverse events to patients and/or their representatives and ensures that staff are aware of discussions and documentation required to comply with these policies.
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10 The Veterans Integrated Service Network 15 Medical Facility Director reviews the events in the patient’s care and conducts additional actions related to the disclosure of adverse events to the patient’s representative as warranted by Veterans Health Administration and Veterans Integrated Service Network 15 Medical Facility.
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11 The Veterans Integrated Service Network 15 Medical Facility Director reviews quality management practices and ensures compliance with Veterans Health Administration guidance related to root cause analysis when future adverse events are identified and takes action as necessary.
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| 19-00266-141 | Staffing and Vacancy Reporting under the MISSION Act of 2018 | Review | ||
1 Ensure VA vacancy data are reported by occupation as required by Section 505(a)(1)(c) of the Mission Act.
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2 Make certain that VA staffing gains and losses data are reported by quarter as required by Section 505(a) part (b) of the MISSION Act.
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3 Annotate limitations clearly within the staffing and vacancy data to improve transparency and usability of the data, to include changes from HR Smart data cleansing efforts.
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4 Ensure that the staffing and vacancy reporting Web-site maintains historical information on the data elements required by the MISSION Act.
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5 Update the methodology for collecting and reporting on VA staffing and vacancy data to ensure consistency in future quarters.
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| 18-02765-144 | Alleged Deficiencies in Out of Operating Room Airway Management Processes at the Colmery-O’Neil VA Medical Center within the VA Eastern Kansas Health Care System, Topeka, Kansas | Hotline Healthcare Inspection | ||
1 The VA Eastern Kansas Health Care System Director implements documentation training for facility staff, including the Associate Chief of Staff for Education, and monitors compliance with out of operating room airway management documentation for completeness and accuracy.
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2 The VA Eastern Kansas Health Care System Director verifies that facility out of operating room airway management policy and out of operating room airway management providers comply with Veterans Health Administration requirements.
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3 The VA Eastern Kansas Health Care System Director ensures that facility out of operating room airway management staff are trained as required and monitor compliance, including tracking verification of out of operating room airway management competencies.
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4 The VA Eastern Kansas Health Care System Director ensures that facility policy and use of Veterans Administration Form 10-0544, Privilege and Competency Verification, is consistent with VHA requirements.
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5 The VA Eastern Kansas Health Care System Director ensures that facility out of operating room airway management workgroups monitor progress toward implementation of Veterans Health Administration Directive 1157(1), Out of Operating Room Airway Management, June 14, 2018, Amended September 19, 2018.
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6 18-02765-144The VA Eastern Kansas Health Care System Director verifies that facility leaders review the VetPro process and ensures all credentialing and privileging files are complete as required by VHA policy and takes action as necessary based on the findings.
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7 The VA Eastern Kansas Health Care System Director verifies that the Cardiopulmonary Resuscitative Committee analyzes and aggregates data and implements desired changes, as outlined Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation, and monitors compliance.
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| 18-03260-102 | Alleged Unapproved Acquisition of a Robotic Surgical System for the W.G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, North Carolina | Audit | ||
1 The Deputy Under Secretary for Health for Operations and Management directs the Healthcare Technology Management Program Office to clarify High Cost, High Tech approval requirements to Veterans Integrated Service Network 6 officials, including biomedical engineers, logistics staff, equipment specialists, and financial officers, and to the Veterans Health Administration Procurement and Logistics Office.
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2 The Veterans Integrated Service Network 6 network director updates and disseminates VHA requirements to request Assistant Deputy Under Secretary for Health for Administrative Operations approvals for High Cost, High Tech purchases that cost over $1 million, including surgical robots, to the members of the Veterans Integrated Service Network 6 Capital Investment Board and Veterans Integrated Service Network 6 staff.
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3 The Veterans Integrated Service Network 6 Capital Investment Board meets each fiscal year to ensure that all facility equipment requests more than $1 million are reviewed in a timely manner, including fiscal year-end purchases.
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| 18-04673-138 | Comprehensive Healthcare Inspection of the Jesse Brown VA Medical Center, Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures utilization management reviewers complete at least 75 percent of all inpatient stay reviews and monitors the reviewers’ compliance.
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2 The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
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3 The facility director ensures the Cardiopulmonary Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and monitors the Cardiopulmonary Resuscitation Committee’s compliance.
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4 The chief of staff ensures that clinical managers initiate focused professional practice evaluations that include clearly delineated timeframes and monitors clinical managers’ compliance.
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5 The facility director makes certain that controlled substances program staff perform one random day’s reconciliation of controlled substances returned to pharmacy from every automated dispensing unit during monthly inspections and monitors the program staff’s compliance.
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6 The facility director ensures that the controlled substances inspectors verify documentation for two signatures for any waste of partial doses and monitors controlled substances inspectors’ compliance.
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7 The facility director confirms that mental health and primary care providers complete military sexual trauma mandatory training requirements no later than 90 days after entering their position and monitors providers’ compliance.
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8 The chief of staff ensures clinicians provide and document patient/caregiver education and monitors clinicians’ compliance.
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9 The chief of staff makes certain that program managers implement a process for trackingcervical cancer screening data and monitors program managers’ compliance.
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10 The chief of staff confirms that providers notify patients of abnormal cervical pathology results within the required timeframe and monitors providers’ compliance.
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11 The facility director ensures that the urgent care center is discontinued and patient needs and flow are more adequately addressed in the established emergency department and primary care clinic, and monitors compliance.
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