Combined Assessment Program Review of the Hampton VA Medical Center Hampton, Virginia

The purpose of this 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 180 employees. This review focused on five operational areas. The medical center complied with selected standards in the following two areas (1) emergency department and (2) patient satisfaction. We identified information security and privacy and respiratory hygiene as organizational strengths. We made recommendations for improvements in the following three areas: Environment of Care – Ensure that duress alarms on the locked mental health unit are properly located and functioning and that construction barriers are intact. QM – Review physician privileges to ensure currency of competencies, ensure that all appropriate clinical staff maintain current cardiopulmonary resuscitation certification, improve timeliness of peer review referrals, and improve compliance with requirements in the root cause analysis and disclosure processes. Pharmacy Operations – Properly seal ceilings and install automatic door and light switches in clean rooms.