Comprehensive Healthcare Inspection of the James A. Haley Veterans' Hospital, Tampa, Florida

Report Information

Issue Date
Closure Date
Report Number
19-00011-255
VISN
State
Florida
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
7
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 the James A. Haley Veterans' Hospital, covering leadership, organizational risks, and key processes associated with promoting quality care. For this inspection, 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 facility’s leadership team had been working together for almost seven months, although several had served in their positions for years. Selected survey scores related to employee satisfaction with the facility’s leaders and patient experience survey data revealed scores related to satisfaction with the facility were similar to or better than the VHA averages. The OIG did not identify any substantial organizational risks. The leaders who were permanently assigned were knowledgeable within their scope of responsibility about selected SAIL and SAIL CLC metrics but the leadership team should continue to take actions to sustain and improve performance measures contributing to the SAIL “4-star” and CLC “2-star.” The OIG issued seven recommendations for improvement in the following areas: (1) Medical Staff Privileging • Focused professional practice evaluation (including for cause) processes • Ongoing professional practice evaluation (2) Medication Management: Controlled Substances Inspections • Monthly reviews of automatic dispensing cabinet override reports (3) Mental Health: Military Sexual Trauma Follow-up and Staff Training • MST training (4) Geriatric Care: Antidepressant Use among the Elderly • Patient/caregiver education and understanding of medications • Medication reconciliation (5) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up • Women Veterans Health Committee core membership

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: 4/22/2020
The chief of staff ensures that service chiefs include service-specific criteria for ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2020
The chief of staff ensures that service chiefs clearly define and share in advance the expectations, outcomes, and time limits for focused professional practice evaluations for cause with providers and monitors service chiefs’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/14/2019
The facility director makes certain that the pharmacy or nursing staff complete the review of automatic dispensing cabinets’ override reports and monitors the program staff compliance
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2020
The facility director confirms providers complete military sexual trauma mandatory training no later than 90 days after assuming their position and monitors providers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/9/2020
The chief of staff ensures that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and assess understanding of the education provided and monitors clinicians’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/9/2020
The chief of staff ensures clinicians reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors the clinicians’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2020
The facility director confirms that the Women Veterans Health Committee includes required core members and monitors committee’s compliance.