Comprehensive Healthcare Inspection of the Mann-Grandstaff VA Medical Center in Spokane, Washington

Report Information

Issue Date
Closure Date
Report Number
20-01262-191
VISN
20
State
Idaho
Montana
Washington
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
13
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 Mann-Grandstaff VA Medical Center and multiple clinics in Idaho, Montana, and Washington. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Privileging; 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. At the time of the OIG site visit, the leadership team had worked together for about one month and had vacancies in two of four positions. Employee satisfaction survey results for the medical center and leaders were similar to or higher than Veterans Health Administration averages. Patients generally appeared satisfied with the care provided, but indicated opportunities to improve appointment scheduling for female veterans. The OIG’s review of accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors, but the OIG noted potential risks with the medical center’s expected electronic health record system implementation. Leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance. The OIG issued 13 recommendations for improvement in five areas: (1) Quality, Safety, and Value • Protected peer reviews • Root cause analyses (2) Medical Staff Privileging • Focused professional practice evaluations (3) Mental Health • Patient follow-up • Suicide prevention safety plans • Community outreach activities • Suicide risk training (4) Women’s Health • Gynecologic care coverage • Women veterans health committee • Quality assurance data collection and tracking • Women veterans program manager duties (5) High-Risk Processes • Annual risk analysis • 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)
Closure Date: 7/7/2022
The Medical Center Director determines reasons for noncompliance and ensures that the Protected Peer Review Committee completes final reviews within 120 calendar days or has a written extension request approved by the Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/30/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures root cause analyses’ corresponding actions and outcome measures show sustained improvement.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define in advance, communicate, and document expectations for focused professional practice evaluations in practitioners’ profiles.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Chief of Staff determines the reasons for noncompliance and makes certain that providers conduct four follow-up visits, either face-to-face or telephonic, with the veterans’ preference documented, within the required time frame.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians complete suicide safety plans within the required time frame for patients with High Risk for Suicide Patient Record Flags.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator conducts at least five outreach activities each month.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures employees complete suicide risk and intervention training within 90 days of entering their position and annual refresher training.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that written processes and procedures are in place for 24 hours per day, 7 days per week gynecological care.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required 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)
Closure Date: 7/7/2022
The Medical Center Director evaluates and determines the reasons for noncompliance and makes certain the Women Veterans Program Manager collects and tracks data for follow-up of abnormal mammogram and cervical cytology reports and the timeliness of breast and cervical cancer treatment.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services 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)
Closure Date: 7/7/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that staff who reprocess reusable medical equipment complete competency assessments.