Comprehensive Healthcare Inspection of the Wm. Jennings Bryan Dorn VA Medical Center in Columbia, South Carolina

Report Information

Issue Date
Closure Date
Report Number
20-00130-25
VISN
7
State
South Carolina
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
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
14
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 Wm. Jennings Bryan Dorn VA Medical Center and multiple outpatient clinics in South Carolina. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection focused on 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 medical center leaders had worked together for nearly two years at the time of the on-site inspection. Survey results indicated that employees were generally satisfied. However, patient survey results indicated multiple opportunities for medical center leaders to improve satisfaction. Review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. Medical center leaders, other than the Chief of Staff, were knowledgeable within their scope of responsibilities about employee and patient satisfaction survey results and Veterans Health Administration data and/or factors contributing to specific poorly-performing Strategic Analytics for Improvement and Learning quality and efficiency measures. The OIG issued 14 recommendations for improvement in six areas: (1) Medical Staff Privileging • Ongoing professional practice evaluations • Provider exit reviews (2) Environment of Care • Infection prevention and medication safety • Environmental cleanliness • Privacy (3) Medication Management • Aberrant behavior risk assessment • Informed consent • Patient follow-up (4) Mental Health • Patient follow-up • Suicide prevention training (5) Women’s Health • Gynecologic care coverage • Women Veterans Health Committee membership and attendance (6) High-Risk Processes • Equipment 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: 8/18/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs’ reprivileging recommendations are based on ongoing professional practice evaluation activities and licensed independent practitioner files contain properly completed evaluation forms with supporting data.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Medical Executive Board’s decision to recommend continuation of privileges is based on complete ongoing professional practice evaluation results.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2021
The Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed health care professionals’ departure from the medical center.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and makes certain that staff dispose of contaminated instruments and used medications appropriately.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures managers remove patient care supplies from shipping cartons and all corrugated boxes prior to putting items in clean storage areas.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2020
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that staff secure protected health information when transporting laboratory specimens from the clinic to the medical center.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of substance abuse, mental health problems or disorders, and aberrant drug-related behaviors on all patients prior to initiating long- term opioid therapy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers conduct follow-up assessments that include adherence to the plan of care and effectiveness of interventions within three months of initiating long-term opioid therapy.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that mental health providers collaborate with the Suicide Prevention Coordinator after unsuccessful contact attempts with patients flagged as high risk for suicide who miss mental health appointments and properly document those efforts.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2020
The Director evaluates and determines any additional reasons for noncompliance and ensures all staff complete annual suicide prevention refresher training
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2020
The Chief of Staff determines the reasons for noncompliance and ensures that gynecological care coverage is available 24 hours a day, 7 days per week.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2021
The Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are appointed and attend Women Veterans Health Committee meetings.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2021
The Associate Director Patient Care/Nursing Service evaluates and determines the reasons for noncompliance and ensures that high-level disinfected endoscopes are stored properly.