Combined Assessment Program Review of the Northampton VA Medical Center Leeds, Massachusetts

The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we provided fraud and integrity awareness training to 41 employees. The review covered eight operational activities. The medical center complied with selected standards in the following three activities: (1) staffing, (2) pharmacy operations, and (3) survey of healthcare experiences of patients. We identified improved patient and employee safety and improved patient transfer procedures as organizational strengths. We made recommendations for improvement in the following five activities: Environment of Care – Monitor hand hygiene compliance, repair the canteen roof, test and maintain the elopement prevention system, ensure refrigerator logs include acceptable temperature ranges and contact information, post suicide prevention information in patient care areas, and inspect all emergency carts. QM – Implement a peer review (PR) policy and ensure the PR Committee fulfills requirements, implement a continuous performance monitoring plan for providers and ensure performance data are used for reprivileging, monitor improvement action effectiveness, and monitor and trend radiology studies done by fee basis agencies. Emergency Department/Urgent Care Clinic – Provide written discharge instructions, comply with inter-facility transfer policy, and ensure annual achievement of clinic nurses’ required competencies. Medication Management – Define a timeframe for pain medication effectiveness documentation, ensure interventions to relieve pain are documented, and monitor pain assessment documentation. Coordination of Care – Ensure discharge medications are listed on discharge summaries.