Comprehensive Healthcare Inspection of the Montana VA Health Care System in Fort Harrison

Report Information

Issue Date
Closure Date
Report Number
21-00232-205
VISN
19
State
Montana
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
8
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 Montana VA Health Care System. The inspection covered key clinical and administrative processes associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior. The healthcare system had vacancies in two of the five key leadership positions, with the Quality Management Officer serving as acting Assistant Director and acting Associate Director of Patient Care Services. Survey results indicated opportunities to improve employee attitudes toward leaders, the workplace, and workgroup relationships. Patient experience survey results highlighted opportunities for improvement in outpatient settings. Review of the healthcare system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. The executive leaders were generally knowledgeable about select data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance. The OIG issued eight recommendations for improvement in four areas: (1) Quality, Safety, and Value • Systems redesign and improvement program reporting structure • Surgical work group processes • Action item implementation and monitoring (2) Registered Nurse Credentialing • Primary source verification of registered nurses’ licenses (3) Mental Health • Suicide prevention training (4) High-Risk Processes • Disruptive behavior committee attendance • Disruptive behavior training

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: 8/19/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Systems Redesign and Improvement Coordinator reports directly to the Director or one supervisory level below the Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly and core members consistently attend meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group reviews surgical deaths and National Surgery Office surgical quality reports, analyzes efficiency and utilization metrics, and recommends appropriate actions to the System Director.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that specific action items are implemented and monitored when problems or opportunities for improvement are identified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory training prior to developing suicide safety plans.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.