Comprehensive Healthcare Inspection of the VA Western New York Healthcare System, Buffalo, New York

Report Information

Issue Date
Closure Date
Report Number
18-04666-55
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
Patient Safety
Medical Staff Privileging Credentialing
Major Management Challenges
Healthcare Services
Recommendations
18
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the VA Western New York Healthcare System covering clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The executive leadership team was generally stable, despite the assistant director also serving as the acting associate director. Employee satisfaction and patient experiences in the inpatient care setting were worse than VHA. The leaders should review steps to identify cases that may need institutional disclosures and evaluate the process of identifying improvement opportunities. Executive leadership team members were knowledgeable about Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics and the actions necessary to sustain and improve performance that contribute to the SAIL “4-star” quality ratings. The OIG issued 18 recommendations for improvement: (1) Quality, Safety, and Value • Basic or advanced cardiac life support certification for resuscitation staff (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes • Required review and evaluation of privileging requests (3) Environment of Care • Environmental cleanliness • Mental health seclusion room safety • Review of inventory of assets and resources (4) Medication Management • Review of balance adjustments • Controlled substance inventories (5) Mental Health • Military Sexual Trauma training (6) Geriatric Care • Patient/caregiver education • Medication reconciliation (7) Women’s Health • Full-time women veterans program manager • Women Veterans Health Committee membership and quarterly meetings (8) Emergency Departments and Urgent Care Center Operations • Licensed provider staffing • Equipment/supplies to treat sexual assault patients

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: 12/8/2020
The chief of staff confirms that all team members responding to resuscitation events have basic or advanced cardiac life support certification and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff ensures the service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The chief of staff ensures that service chiefs include required gastroenterology and pathology specific criteria for those specialties in ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff ensures that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The chief of staff ensures that the Executive Committee of the Medical Staff reviews and evaluates licensed independent practitioners’ initial and re-privileging requests prior to making recommendations to the facility director and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The associate director ensures that a safe and clean environment is maintained throughout the facility and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The associate director makes certain mental health seclusion room floors are cushioned.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The associate director ensures the required inventory of assets and resources is created and reviewed annually by the Emergency Management Committee and approved by executive leaders and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director ensures that staff who conduct monthly review of balance adjustments not be the same staff that perform and document the balance adjustments and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The facility director makes certain that controlled substances coordinators maintain necessary records and controlled substance inspectors conduct monthly physical inventory of the controlled substances storage area that are completed on the day initiated and monitors controlled substance coordinator’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The facility director makes certain that the pharmacy staff complete the pharmacy inventory checks as required and monitors staff compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff ensures mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The chief of staff makes certain that clinicians provide education to the patient and/or caregiver about the safe and effective use of newly prescribed medications and monitors the clinicians’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The chief of staff ensures clinicians review and reconcile patients’ medications and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors the clinicians’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director confirms that the facility has a full-time women veterans program manager and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The facility director makes certain that the Women Veterans Health Committee meets quarterly, is comprised of required core members, reports to executive quadrad leadership with signed minutes, and monitors the committee’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2021
The facility director makes certain that the emergency department has a licensed physician privileged to staff the department during all hours of operation and monitors the department’s compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director makes certain the emergency department has the necessary resources readily available to treat sexual assault patients and monitors compliance.