Comprehensive Healthcare Inspection of the Syracuse VA Medical Center in New York

Report Information

Issue Date
Report Number
23-00016-132
VISN
2
State
New York
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Medical Staff Privileging Credentialing
Mental Health
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
12
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Syracuse VA Medical Center, which includes multiple outpatient clinics in New York. This evaluation focused on five key operational areas:
•    Leadership and organizational risks
•    Quality, safety, and value
•    Medical staff privileging
•    Environment of care
•    Mental health (suicide prevention initiatives)

The OIG issued 12 recommendations for improvement in four areas:
1.    Quality, safety, and value
•    Peer review committee
    •    Peer review level reassignments
    •    Review of data by medical executive committee

2.    Medical staff privileging
•    Ongoing Professional Practice Evaluation completion
•    Specialty-specific criteria for professional practice evaluations

3.    Environment of care
•    Environment of care inspections
•    Safe and clean patient care areas
•    Mental health inpatient unit:
    •    Panic and over-the-door alarm testing
    •    Maintaining a safe environment
    •    Ceiling tiles checked semiannually
•    Biomedical staff inspection and testing of medical equipment
•    VISN oversight of biomedical program

4.    Mental health
•    Comprehensive Suicide Risk Evaluation completion
 

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures staff record the Peer Review Committee’s formal discussions related to changes in peer review level assignments in the meeting minutes.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures the Medical Staff Executive Committee reviews data provided by the Peer Review Committee to determine the need for further action.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs complete Ongoing Professional Practice Evaluations prior to reprivileging to ensure continuous delivery of quality care.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs use specialty-specific criteria in the professional practice evaluations of licensed independent practitioners.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures the Comprehensive Environment of Care Rounds Coordinator or designee schedules environment of care inspections and staff complete and document them at the required frequency.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures staff keep patient care areas safe and clean.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff document police response times to panic alarm testing in the mental health inpatient unit.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff test over-the-door alarms based on the manufacturer’s recommendations for mental health inpatient unit sleeping rooms.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff check all mental health inpatient unit ceiling tiles semiannually.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures the Medical Center Director has sufficient biomedical staff and confirms they inspect and test all medical equipment for scheduled maintenance.

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures compliance with VHA Directive 1860, Biomedical Engineering Performance Monitoring and Improvement, for oversight structure of the medical center’s biomedical program.

No. 12
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures designated staff complete the Comprehensive Suicide Risk Evaluation on the same calendar day as a positive suicide risk screen, when clinically appropriate, for all ambulatory care patients.