Comprehensive Healthcare Inspection of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts

Report Information

Issue Date
Closure Date
Report Number
19-00043-66
VISN
1
State
Massachusetts
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
21
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at Edith Nourse Rogers Memorial Veterans Hospital (the facility), covering leadership, organizational risks, and key processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The leaders had been working together for approximately 15 months. Selected employee satisfaction results indicated general satisfaction with facility leaders, but opportunities exist to improve workplace attitudes. Leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center metrics but should continue to act to sustain and improve performance measures contributing to the SAIL “5-star” and community living center “2-star” quality ratings. The OIG issued 21 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data • Root cause analysis processes (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (3) Environment of Care • Environmental safety and cleanliness • Medical supply storage • Panic alarm testing • Comprehensive emergency management plan (4) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • Military sexual trauma training (5) Geriatric Care: Antidepressant Use among the Elderly • Justification for medication initiation • Patient and/or caregiver education and evaluation of understanding • Medication reconciliation processes (6) Women Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership (7) High-Risk Processes: Emergency Department and Urgent Care Center Operations • 24-hour Urgent Care Center operations waiver • Appointed Urgent Care Center medical director • Urgent Care Center staffing • Urgent Care Center support services availability

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: 1/4/2022
The facility director makes certain that required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020
The facility director ensures that the patient safety manager completes the minimum requirement of eight root cause analyses each year and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2021
The facility director ensures that the patient safety manager submits each root cause analysis to the National Center for Patient Safety within the required time frame and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2021
The chief of staff ensures that service chiefs clearly define and communicate focused professional practice evaluation criteria in advance with providers and monitors service chiefs’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The chief of staff ensures that service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
The chief of staff ensures that ongoing professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020
The chief of staff ensures that service chiefs clearly define, share, and document in advance the expectations and outcomes for time-limited focused professional practice evaluations for cause with providers and monitors service chiefs’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2021
The associate director ensures that floors and ceilings tiles are repaired, cleaned, and maintained and window screens are replaced and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2021
The associate director ensures expired medical supplies are removed from supply rooms and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020
The associate director ensures that VA police test panic alarms and evidence of testing is documented and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The facility director ensures that the comprehensive emergency management plan and its required elements are reviewed annually by the Emergency Management Committee and approved by executive leadership and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2021
The facility director ensures an emergency operations plan is developed and reviewed annually.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020
The facility director confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2021
The chief of staff makes certain that clinicians justify and document the reason for initiating the medication and monitors clinicians’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2021
The chief of staff ensures that clinicians provide and document patient and/or caregiver education and evaluate understanding of education provided about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2021
The chief of staff ensures clinicians review and reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health record and monitors clinicians’ compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2023
The facility director confirms that the Women Veterans Health Committee is comprised of required core members and monitors the committee’s compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The facility director requests the required waiver for urgent care clinic operations 24 hours a day, 7 days a week and continues such operations only if the waiver is approved.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2020
The facility director makes certain that a medical director for the urgent care center is formally appointed.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The chief of staff ensures the urgent care center has a minimum of two registered nurses on staff during all hours of operation and monitors compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2021
The chief of staff ensures that appropriate support services are in place during all hours of UCC operation and monitors compliance.