Comprehensive Healthcare Inspection of the Robert J. Dole VA Medical Center in Wichita, Kansas

Report Information

Issue Date
Closure Date
Report Number
19-06872-199
VISN
15
State
Kansas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Patient Safety
Medical Staff Privileging Credentialing
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
26
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 Robert J. Dole VA Medical Center and multiple outpatient clinics in Kansas. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; 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. The executive leadership team had worked together since 2018. The Director had served in the role since 2016. Employee satisfaction scores revealed opportunities for the Associate Director for Patient Care Services to improve employee attitudes towards senior leaders. Patients appeared satisfied with their care and leaders appeared actively engaged. The OIG identified significant concerns regarding incident review processes and identifying sentinel events and/or institutional disclosures. Leaders were able to speak knowledgeably about performance actions and survey results. Leaders were also generally knowledgeable about Strategic Analytics for Improvement and Learning data. The OIG issued 26 recommendations for improvement in all eight areas: (1) Quality, Safety, and Value • Utilization management data review • Root cause analysis processes • Annual patient safety report (2) Medical Staff Privileging • Professional practice evaluations • Provider exit reviews (3) Environment of Care • Supply storage • Environmental cleanliness • Privacy (4) Medication Management • Behavior risk assessment • Informed consent • Patient follow-up (5) Mental Health • Patient follow-up • Suicide safety plans • Staff training (6) Care Coordination • Multidisciplinary committee (7) Women’s Health • Women Veterans Health Committee membership (8) High-Risk Processes • Annual risk analysis • Airflow and infection control • Endoscope storage

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: 1/15/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures all required representatives consistently participate in interdisciplinary reviews of utilization management data.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that root cause analyses include all required review elements and are properly documented in the VHA Patient Safety Information System.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that root cause analysis actions are implemented and properly documented in the VHA Patient Safety Information System.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that the Patient Safety Manager or designee provides an annual patient safety report to medical center leaders.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures clinical managers define in advance, communicate, and document expectations for focused professional practice evaluations in provider profiles.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures clinical managers consistently collect and review ongoing professional practice evaluation data.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that Medical Professional Standards Board meeting minutes consistently reflect the review of professional practice evaluation results when recommending continuation of privileges.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff determines reason(s) for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals departing the medical center.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Chief of Staff determines reason(s) for noncompliance and ensures the departing licensed healthcare professional’s first- or second-line supervisor appropriately signs the exit review form.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Associate Director determines reason(s) for noncompliance and ensures that patient care supply areas are properly designated, and adequate temperature and humidity controls are continuously monitored and maintained.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that a safe and clean environment is maintained throughout the medical center.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Chief of Staff determines the reason(s) for noncompliance and ensures that personally identifiable information is protected when transporting information or specimens from the clinics to the medical center.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that clinicians complete a behavioral risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors on patients prior to initiating long-term opioid therapy.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/13/2022
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients who are initiating long-term opioid therapy.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures healthcare providers follow up with patients within three months after initiating long-term opioid therapy.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Chief of Staff determines reason(s) for noncompliance and makes certain that clinicians conduct four follow-up appointments within the required time frame and document the patient’s preference for telephonic follow-up, if warranted.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that clinicians complete safety plans in a timely manner and that all required elements—including firearm and opioid safety—are assessed for patients with High Risk for Suicide Patient Record Flags.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures clinical and nonclinical staff receive annual suicide prevention refresher training.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and appoints a multidisciplinary committee responsible for life-sustaining treatment decision reviews that includes representatives from three or more different disciplines.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that Sterile Processing Services reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and ensures that Sterile Processing Services maintain required airflow parameters for areas where reusable medical equipment is reprocessed.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2020
The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and ensures that staff avoid eating, drinking, and/or storing food items in areas where decontamination, sterilization, or clean/sterile storage occurs.148
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Associate Director for Patient Care Services determines reason(s) for noncompliance and ensures that staff properly store endoscopes.