Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-00564-170 | Clinical Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
Closure Date:
2 We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
Closure Date:
3 We recommended that the Patient Safety Manager provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.
Closure Date:
4 We recommended that Environment of Care Council meeting minutes document discussion of environment of care rounds deficiencies, include corrective actions taken to address rounds deficiencies, and track actions taken in response to identified deficiencies to closure.
Closure Date:
5 We recommended that facility managers ensure fire extinguisher locations are clearly identified.
Closure Date:
6 We recommended that facility managers ensure information technology network room visitor logs contain all the required elements and monitor compliance.
Closure Date:
7 We recommended that employees store expired medications separately from medications available for administration and that facility managers monitor compliance.
Closure Date:
8 We recommended that facility managers ensure ice machines and refrigerators in patient nourishment kitchens are clean and monitor compliance.
Closure Date:
9 We recommended that facility managers ensure standard operating procedures for the bronchoscope are consistent with the manufacturer's instructions for use.
Closure Date:
10 We recommended that the facility collect and report data on patient transfers out of the facility.
Closure Date:
11 We recommended that facility managers ensure transfer notes written by acceptable designees contain a staff/attending physician countersignature and monitor compliance.
Closure Date:
12 We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
Closure Date:
13 We recommended that the Chief of Pathology and Laboratory Medicine Service ensure the point-of-care testing procedure manual is readily available to employees.
Closure Date:
14 We recommended that employees ensure glucometers are clean before and after use and that clinical managers monitor compliance.
Closure Date:
15 We recommended that providers perform history and physical examinations within 30 calendar days prior to the moderate sedation procedure and that facility managers monitor compliance.
Closure Date:
16 We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
Closure Date:
17 We recommended that the facility correct the deficiencies identified for the Mental Health Residential Rehabilitation Treatment Program and that documentation reflects correction actions taken.
Closure Date:
18 We recommended that facility managers ensure the review of the hazardous materials inventory at the Marshalltown CBOC occurs twice within a 12-month period.
Closure Date:
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| 16-00565-154 | Clinical Assessment Program Review of the Orlando VA Medical Center, Orlando, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
Closure Date:
2 We recommended that facility managers implement the use of a visitors log during non-business hours and monitor compliance.
Closure Date:
3 We recommended that the facility perform quality control testing on all endoscopes and that facility managers monitor compliance.
Closure Date:
4 We recommended that the facility review quality assurance data for the anticoagulation management program quarterly as defined by local policy and that facility managers monitor compliance.
Closure Date:
5 We recommended that for patients transferred out of the facility, transferring providers consistently include documentation of patient or surrogate informed consent, VA Form 10-2649B, in transfer documentation and that facility managers monitor compliance.
Closure Date:
6 We recommended that providers consistently complete VA Form 10-2649A for patients transferred out of the facility and that facility managers monitor compliance.
Closure Date:
7 We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
Closure Date:
8 We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement and ensure Chief of Staff or designee approval of Orders of Behavioral Restriction.
Closure Date:
9 We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
Closure Date:
10 We recommended that Domiciliary Care for Homeless Veterans and Substance Abuse Residential Rehabilitation Treatment Program employees at Lake Baldwin conduct and document daily bed checks and that program managers monitor compliance.
Closure Date:
11 We recommended that facility managers ensure all Mental Health Residential Rehabilitation Treatment Program emergency exit door alarms are functional and turned on at all times and that program managers monitor compliance.
Closure Date:
12 We recommended that facility managers ensure all closed circuit television monitoring cameras at the Domiciliary Care for Homeless Veterans and Substance Abuse Residential Rehabilitation Treatment Programs have recording capability and that program managers monitor compliance.
Closure Date:
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| 17-02644-202 | Interim Summary Report - Healthcare Inspection - Patient Safety Concerns at the Washington DC VA Medical Center, Washington, DC | Hotline Healthcare Inspection | ||
1 We recommended the Under Secretary for Health take immediate action to ensure that necessary supplies and equipment are available in patient care areas at the Washington DC, VA Medical Center.
Closure Date:
2 We recommended the Under Secretary for Health take immediate action to implement an effective inventory management system throughout the Washington DC, VA Medical Center.
Closure Date:
3 We recommended the Under Secretary for Health take immediate action to ensure that current stock at the Washington DC, VA Medical Center does not include recalled equipment or supplies.
Closure Date:
4 We recommended the Under Secretary for Health take all appropriate steps to ensure that the environmental integrity of the sterile satellite storage areas complies with VA policy.
Closure Date:
5 We recommended the Under Secretary for Health take immediate action to create an inventory and establish accountability over the equipment and supplies in the off-site warehouse.
Closure Date:
6 We recommended the Under Secretary for Health take all appropriate steps to ensure that the Washington DC, VA Medical Center and Veterans Integrated Service Network arrange the orderly movement of goods and supplies from the warehouse that minimizes losses to the Government.
Closure Date:
7 We recommended the Under Secretary for Health deploy additional logistics staff with in-depth Generic Inventory Package experience to the Washington DC, VA Medical Center until reasonable assurances can be provided that existing logistics staff can maintain an effective inventory management system.
Closure Date:
8 We recommended the Under Secretary for Health expedite hiring of permanent positions at the Washington DC, VA Medical Center, to include the Associate VA Medical Center Director, the Nurse Executive, the Chief of Logistics, Assistant Chief of Logistics, and supply technicians.
Closure Date:
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| 15-00223-196 | Healthcare Inspection – Peer Review for Quality Management Concerns, Huntington VA Medical Center, Huntington, West Virginia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that peer reviewers identify and evaluate surgical and non-surgical clinical events [redacted pursuant to 38 U.S.C. § 5705].
Closure Date:
2 We recommended that the Facility Director maintain full compliance with the Veterans Health Administration’s peer review directive when service-level committees conduct initial peer reviews and consider ensuring secondary review of all such cases [redacted pursuant to 38 U.S.C. § 5705].
Closure Date:
3 We recommended that the Facility Director ensure that the Peer Review Committee provides final Level of Care assignments in writing for all cases brought before it.
Closure Date:
4 We recommended that the Facility Director ensure that service chiefs select peer reviewers to conduct initial peer reviews and that protected peer review processes provide means for peer reviewers to withdraw when uncomfortable about conducting reviews.
Closure Date:
5 We recommended that the Facility Director ensure that initial peer reviewers possess the qualifications required of peers relative to the episodes of care under review.
Closure Date:
6 We recommended that the Facility Director review all cases [redacted pursuant to 38 U.S.C. § 5705]. and repeat the initial peer review process for those cases not conducted in compliance with the Veterans Health Administration’s peer review directive.
Closure Date:
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| 16-03920-197 | Evaluation of Computed Tomography Radiation Monitoring in Veterans Health Administration Facilities | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure a medical physicist inspects computed tomography scanners after completion of repairs or modifications that affect the dose or image quality prior to returning the scanners to clinical service.
Closure Date:
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| 16-00376-133 | Review of Unauthorized System Interconnection at the VA Regional Office in Wichita, Kansas | Audit | ||
1 We recommended the Director of the Wichita VA Regional Office implement a local process for managing all Veterans Service Organization service requests and document pertinent roles and responsibilities within a Memorandum of Understanding.
Closure Date:
2 We recommended the Assistant Secretary for Information and Technology implement review processes to monitor the performance of the facility chief information officers, information security officers, and technical staff on the identification of external system interconnections and the required change control processes.
Closure Date:
3 We recommended the Assistant Secretary for Information and Technology, in conjunction with the Wichita VA Regional Office Director, ensure that VA's system interconnection with the Kansas Commission on Veterans Affairs Office is brought into compliance with VA Information Security requirements and is authorized by an Interconnection Security Agreement and Facility Compliance Report.
Closure Date:
4 We recommended the Assistant Secretary for Information and Technology conduct an annual review of all Veterans Service Organization systems connected to VA¿s network and ensure that appropriate Interconnection Service Agreements are in place and enforced for those connections.
Closure Date:
5 We recommended the Assistant Secretary for Information Technology implement improved change management controls to prevent the establishment of Virtual Private Network concurrent network connections that are not in accordance with VA policy.
Closure Date:
6 We recommended the Director of the Wichita VA Regional Office implement a local process for managing all Veterans Service Organization service requests and document pertinent roles and responsibilities within a Memorandum of Understanding.
Closure Date:
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| 16-00572-179 | Clinical Assessment Program Review of the VA Salt Lake City Health Care System, Salt Lake City, Utah | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data semi-annually and that facility managers monitor compliance.
Closure Date:
2 We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
Closure Date:
3 We recommended that Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies, the specific deficiencies, corrective actions taken to address identified deficiencies, and resolutions.
Closure Date:
4 We recommended that facility managers ensure attendance is documented for all fire drills.
Closure Date:
5 We recommended that facility managers ensure fire drills have documented critiques.
Closure Date:
6 We recommended that facility managers ensure eye protection equipment is readily available for employees.
Closure Date:
7 We recommended that facility managers ensure standard operating procedures for the colonoscopes and endoscopes for esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography are consistent with manufacturer instructions for use.
Closure Date:
8 We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive training at orientation for the types of reusable medical equipment they reprocess.
Closure Date:
9 We recommended that the facility consistently review and report all quality assurance data measures for the anticoagulation management program quarterly and that facility managers monitor compliance.
Closure Date:
10 We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments knowledge of standard terminology, pharmacology of anticoagulants, monitoring requirements, dose calculation, common side effects, nutrient interactions associated with anticoagulation therapy, and drug to drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
Closure Date:
11 We recommended that the facility collect and report data on patient transfers out of the facility.
Closure Date:
12 We recommended that the facility monitor and evaluate patient transfers as part of the quality management program.
Closure Date:
13 We recommended that the Chief of Pathology and Laboratory Medicine Service ensure the point-of-care testing procedure manual is readily available to employees.
Closure Date:
14 We recommended that the Chief of Pathology and Laboratory Medicine Service ensure employees who perform point-of-care glucose testing comply with facility policy for managing critical glucose values.
Closure Date:
15 We recommended that providers include history of previous adverse experience with sedation or anesthesia in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.
Closure Date:
16 We recommended that clinical teams, including the providers performing the procedures, conduct and document timeouts using a checklist prior to moderate sedation procedures and that facility managers monitor compliance.
Closure Date:
17 We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitor compliance.
Closure Date:
18 We recommended that the Patient Safety Manager and Patient Advocate consistently attend Disruptive Behavior Committee meetings.
Closure Date:
19 We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
Closure Date:
20 We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
Closure Date:
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| 15-04976-191 | Healthcare Inspection – Alleged Quality of Care Concerns, VA Greater Los Angeles Healthcare System, Los Angeles, California | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that nursing staff comply with pressure ulcer documentation requirements and physician providers routinely document participation in the interdisciplinary plan for patients with pressure ulcers.
Closure Date:
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| 15-05379-146 | Audit of VHA's Patient Advocacy Program | Audit | ||
1 We recommended the Under Secretary for Health update patient advocate policies and procedures to ensure they meet current needs.
Closure Date:
2 We recommended the Under Secretary for Health develop procedures to ensure pertinent program information is recorded in a standardized format in the Patient Advocate Tracking System.
Closure Date:
3 We recommended the Under Secretary for Health ensure responsible officials and staff perform patient complaint processing activities in accordance with policies and procedures, such as assuring required program information is recorded and trended at the local and national level.
Closure Date:
4 We recommended the Under Secretary for Health work with the Assistant Secretary for Information and Technology to ensure its Patient Advocate Tracking System meets current program requirements for efficient complaint processing and reporting.
Closure Date:
5 We recommended the Under Secretary for Health establish controls to ensure that patient advocate staffing levels are sufficient to support patient advocate workload estimates.
Closure Date:
6 We recommended the Under Secretary for Health provide patient advocates with periodic formal documented training concerning their responsibilities and utilizing the Patient Advocate Tracking System.
Closure Date:
7 We recommended the Under Secretary for Health implement mechanisms to ensure that privileges and access rights to the Patient Advocate Tracking System are regularly reviewed and extended based upon specific job duties and the need to know.
Closure Date:
8 We recommended the Assistant Secretary for Information and Technology work with the Under Secretary for Health to fully assess the Patient Advocate Tracking System security and operational risks and to initiate appropriate corrective actions, including requesting the authority to operate the Patient Advocate Tracking System, if appropriate.
Closure Date:
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| 16-03743-193 | Evaluation of the Quality, Safety, and Value Program in Veterans Health Administration Facilities Fiscal Year 2016 | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure clinical managers evaluate licensed independent practitioners’ ongoing professional performance regularly according to the frequency required by facility policy.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network managers and facility senior managers, ensure clinical managers implement the improvement actions recommended by the Peer Review Committee.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure Utilization Managers complete at least 75 percent of all required reviews and designated Physician Utilization Management Advisors document their review decisions in the Veterans Health Administration’s utilization management database.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure Patient Safety Managers enter all patient incidents into the Veterans Health Administration’s web-based patient incident database, complete the minimum number of root cause analyses, provide feedback about the root cause analyses findings to the individuals or departments who reported the incidents, and submit patient safety reports to facility leaders at least annually.
Closure Date:
5 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure committees and teams consistently implement and evaluate corrective actions from quality, safety, and value activities.
Closure Date:
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15168