Comprehensive Healthcare Inspection of the Carl Vinson VA Medical Center in Dublin, Georgia

Report Information

Issue Date
Report Number
20-00130-06
VISN
7
State
Georgia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Major Management Challenges
Healthcare Services
Recommendations
17
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Carl Vinson VA Medical Center and multiple outpatient clinics in Georgia. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The executive leadership team had worked together for five weeks prior to the OIG’s on-site visit. The leadership team had vacancies in three of the four key positions since the previous healthcare inspection. Survey results revealed opportunities for the executive team to improve employee satisfaction. Patient experience survey results were generally less favorable than Veterans Health Administration national averages. The OIG’s review of accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were knowledgeable within their scope of responsibilities about selected Strategic Analytics for Improvement and Learning data. The OIG issued 17 recommendations for improvement in seven areas: (1) Quality, Safety, and Value • Committee processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit reviews (3) Medication Management • Quality measure oversight (4) Mental Health • Suicide prevention training (5) Care Coordination • Goals of care conversations (6) Women’s Health • Women’s health primary care providers • Committee membership and attendance (7) High-Risk Processes • Reusable medical equipment inventory file • Standard operating procedures • Annual risk analysis • Eyewash station testing • Quality assurance monitoring • Reprocessing and storage area physical inspections • Competency assessments

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)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures specific action items are developed and documented in the Quality Executive Board
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff determines the reasons for noncompliance and ensures clinical managers define in advance, communicate, and document expectations for focused professional practice evaluations in practitioner profiles.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff determines the reasons for noncompliance and makes certain that all focused professional practice evaluations include defined time frames.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals’ departure from the medical center.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff determines the reasons for noncompliance and makes certain that the Pain Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that nonclinical staff receive the required Operation S.A.V.E. training during new employee orientation.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete and document goals of care conversations prior to hospice referrals.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage when there is only one designated provider.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required core members are assigned to and consistently attend Women Veterans Health Committee meetings.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief maintains an accurate file for all reusable medical equipment that includes the current manufacturers’ instructions for use.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that standard operating procedures align with the manufacturers’ instructions for use, are reviewed at least every three years, and are updated when there is a change.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that written records of weekly eyewash station testing are maintained.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and certifies that Sterile Processing Services staff complete and document liquid disinfectant solution testing to ensure the minimum effective concentration of the active ingredient is achieved.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services determines the reasons for noncompliance and makes certain that annual airflow testing is conducted in the Gastroenterology Sterile Processing Services storage room.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and verifies that eating, drinking, and food item storage is prohibited where the processes of decontamination, sterilization, or clean and sterile storage are performed.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services staff receive properly completed competency assessments for reprocessing reusable medical equipment.