Combined Assessment Program Review of the Birmingham VA Medical Center, Birmingham, Alabama

Report Information

Issue Date
Closure Date
Report Number
11-01295-232
VISN
State
Alabama
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
8
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we also provided fraud and integrity awareness briefings to 234 employees. This review focused on eight operational activities. The facility complied with selected standards in the following three activities: (1) enteral nutrition safety, (2) medication management, and (3) registered nurse competencies. The facility’s reported accomplishments were the operating room systems redesign and the patient orientation program. We made recommendations for improvements in the following five activities: Coordination of care. Environment of care. Management of workplace violence. Physician credentialing and privileging. QM.

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)
Closure Date: 4/17/2012
We recommended that processes be strengthened to ensure that QM data is consistently analyzed and that corrective actions are evaluated for effectiveness.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2012
We recommended that the designated UM Ad-Hoc Committee reviews UM data and that the facility approves the case exemptions for Physician UM Advisor review.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2012
We recommended that PR data summaries include all required elements and that the PRC monitor closure of issues identified or referred for follow-up to other venues.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2012
We recommended that ongoing FPPE be completed within the defined 12-month period and that monitoring data be maintained in the physicians¿ profiles.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2012
We recommended that adequate competency data be maintained in all physicians' profiles.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2012
We recommended that processes be strengthened to ensure that all violent incidents involving patients are discussed at the DBC.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2012
We recommended that annual bloodborne pathogens training and N95 respirator fit testing be completed and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2012
We recommended that processes be strengthened to ensure that all components of written AD notification are provided to patients and that notification is documented in the medical record.