Comprehensive Healthcare Inspection of the VA Bedford Healthcare System in Massachusetts

Report Information

Issue Date
Report Number
23-00101-137
VISN
1
State
Massachusetts
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Mental Health
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
5
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 VA Bedford Healthcare System, which includes the Edith Nourse Rogers Memorial Veterans’ Hospital in Bedford and three outpatient clinics in Massachusetts. 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 five recommendations for improvement in four areas:
1.    Leadership and organizational risks
•    Institutional disclosures for applicable sentinel events

2.    Quality, safety, and value
•    Root cause analysis for patient safety events

3.    Environment of care
•    Patient care areas clean and free from undue wear
•    Inpatient mental health unit over-the-door alarm testing

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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures leaders conduct institutional disclosures for applicable sentinel events.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures staff complete a root cause analysis for all events assigned an actual or potential safety assessment code score of 3.

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

The Associate Director ensures staff keep patient areas clean and free from undue wear.

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

The Director ensures staff check over-the-door alarms on the mental health inpatient unit according to the manufacturer’s guidelines.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in ambulatory care settings.