Comprehensive Healthcare Inspection Program Review of the James J. Peters VA Medical Center, Bronx, New York

Report Information

Issue Date
Closure Date
Report Number
17-01751-25
VISN
State
New York
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
15
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the James J. Peters VA Medical Center (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; and High-Risk Processes: Moderate Sedation. OIG also provided crime awareness briefings to 162 employees. The facility had generally stable executive leadership and active engagement with employees and patients to maintain high satisfaction scores. Organizational leadership supported patient safety, quality care, and other positive outcomes. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors. OIG noted findings in the five areas of clinical operations reviewed and issued 15 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Frequency of Quality Executive Board meetings • Review of credentialing and privileging data • Utilization management reviews and documentation (2) Medication Management: Anticoagulation Therapy • Use of quality assurance data (3) Coordination of Care: Inter-Facility Transfers • Transfer data reporting and analysis • Documentation for acute patient transfers to other facilities (4) Environment of Care • Environment of care rounds attendance • Panic alarm and security surveillance television system testing • Interdisciplinary Safety Inspection Team training (5) High-Risk Processes: Moderate Sedation • Monitoring of moderate sedation outcome data • Performance of history and physical examinations and pre-sedation assessments • Clinical staff 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: 8/6/2018
The Facility Director ensures the Quality Executive Board meets monthly as required by facility policy, or facility leaders revise the local policy to be consistent with Veterans Health Administration quarterly meeting requirements, and the Facility Director monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2018
The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data twice per year and monitors the managers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2018
The Facility Director ensures clinical managers complete at least 75 percent of allrequired inpatient utilization management reviews and monitors the managers’compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2018
The Facility Director ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2018
The Chief of Staff ensures identification of an interdisciplinary group or committee, ensures review of utilization management data on an ongoing basis, and monitors the group’s compliance with data review policies.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2018
The Facility Director ensures all required anticoagulation management programquality assurance data are collected, analyzed, and reported biannually at Pharmacyand Therapeutics Committee meetings and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The Facility Director ensures inter-facility patient transfer data are analyzed and reported to an identified quality oversight committee assigned these responsibilities and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2018
The Chief of Staff ensures mental health providers consistently document patient or surrogate informed consent and identify the receiving provider when patients are transferred out of the facility and monitors the providers’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2018
The Associate Director ensures locked mental health unit panic alarm testing documentation includes VA Police response time and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2018
The Associate Director ensures the locked mental health unit’s security surveillance television system is included in the annual physical security assessment and is regularly tested and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2017
The Associate Director ensures all members of the Interdisciplinary Safety Inspection Team complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2018
The Facility Director ensures that the use of reversal agents in moderate sedation cases and the presence or absence of adverse events are reported to and trended by the Performance Improvement Committee and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2018
The Chief of Staff ensures providers perform history and physical exams within 30 days prior to the moderate sedation procedure and include all required elements in the history and physical exams and/or pre-sedation assessments and monitors providers’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The Chief of Staff ensures clinical employees who perform, assist with, or supervise moderate sedation procedures have current Basic Life Support certification and moderate sedation training and monitors their compliance.