Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-00116-323 | Combined Assessment Program Review of the VA Connecticut Healthcare System, West Haven, Connecticut | 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 consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
Closure Date:
4 We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
Closure Date:
5 We recommended that facility managers ensure employees follow facility policy for disinfecting exam tables after each patient use and monitor compliance.
Closure Date:
6 We recommended that facility managers ensure annual competency assessment for pharmacy employees who prepare compounded sterile products includes a written test and monitor compliance.
Closure Date:
7 We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
Closure Date:
8 We recommended that the Suicide Prevention Coordinators consistently provide at least five community outreach activities every month and that facility managers monitor compliance.
Closure Date:
9 We recommended that nurse managers accurately monitor the nurse staffing methodology implemented in March 2013 and use the standard nursing hours per patient day calculation to assess nurse staffing adequacy for all units.
Closure Date:
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| 15-03867-287 | Healthcare Inspection - Access and Quality of Care Concerns, Phoenix VA Health Care System, Phoenix, Arizona, and Delayed Test Result Notification, Minneapolis VA Health Care System, Minneapolis, Minnesota | Hotline Healthcare Inspection | ||
1 We recommended that the Acting Veterans Integrated Service Network 18 Director assign a team to review the Phoenix VA Health Care System Emergency Department processes and develop a plan to improve Emergency Department access and flow during times of increased demand.
Closure Date:
2 We recommended that the Acting Veterans Integrated Service Network 18 Director assign a team to review the Phoenix VA Health Care System Emergency Department processes and develop a plan to decrease the number of patients who leave the Emergency Department without being seen by a provider.
Closure Date:
3 We recommended that the Phoenix VA Health Care System Director review current verbal communication practices in the Emergency Department and determine what steps are reasonable to safeguard patient information.
Closure Date:
4 We recommended that the Phoenix VA Health Care System Director assess Emergency Department medication prescription delivery practices to identify potential opportunities to improve pharmacy services.
Closure Date:
5 We recommended that the Phoenix VA Health Care System Director ensure all patients in the Radiology Department are supervised.
Closure Date:
6 We recommended that the Phoenix VA Health Care System Director assess Environmental Management Services staffing needs and take appropriate actions.
Closure Date:
7 We recommended that the Phoenix VA Health Care System Director ensure environment of care concerns identified in this report are corrected and that compliance be monitored.
Closure Date:
8 We recommended that the Phoenix VA Health Care System Director ensure Allergy Clinic staff use standard precautions when disposing used thermometer covers and that compliance be monitored.
Closure Date:
9 We recommended that the Phoenix VA Health Care System Director ensure patients receive recommended preventive medications or are offered substitutions if the medication is not on the VA National Formulary.
Closure Date:
10 We recommended that the Minneapolis VA Health Care System Director ensure that test results are communicated to patients as required.
Closure Date:
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| 16-01040-324 | Combined Assessment Program Summary Report – Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2015 | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Risk Managers invite clinicians involved in Level 2 or 3 peer reviews to submit comments to and/or appear before the Peer Review Committee.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network managers, ensure Facility Directors review all privilege forms annually and document the review.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Medical Staff Coordinators complete the conversion from six-part to two-part credentialing and privileging folders and ensure non-allowed information is not placed in the folders.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Chiefs of Surgery discuss surgical deaths with identified problems in Surgical Work Group meetings.
Closure Date:
5 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities designate a committee to oversee safe patient handling activities, track patient handling injury data, and share data with safe patient handling champions.
Closure Date:
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| 15-03073-275 | Review of VHA’s Alleged Manipulation of Appointment Cancellations at VAMC Houston, TX | Audit | ||
1 We recommended the Veterans Integrated Service Network 16 Director confers with VA’s Office of Accountability Review to determine what, if any, administrative action should be taken based on the factual circumstances developed in this report regarding appointments incorrectly recorded as canceled by patient.
2 We recommended the Veterans Integrated Service Network 16 Director confers with VA’s Office of Accountability Review to determine what, if any, administrative action should be taken regarding instructions to staff to incorrectly record appointments as canceled by patient.
3 We recommended the Veterans Integrated Service Network 16 Director ensure the Director of the Michael E. DeBakey VA Medical Center provides training on when to use clinic versus patient cancellation options and how to identify the clinically indicated appointment date.
4 We recommended the Veterans Integrated Service Network 16 Director ensure the Director of the Michael E. DeBakey VA Medical Center improves scheduling audit processes to ensure that managers conduct a complete review of appointment data to ensure scheduling staff are using the correct cancellation type and clinically indicated or preferred appointment date.
Closure Date:
5 We recommended the Veterans Integrated Service Network 16 Director ensure the Director of the Michael E. DeBakey VA Medical Center makes sure managers take corrective action when audits identify deficiencies in scheduling staff’s use of appointment cancellation type and clinically indicated or preferred appointment dates.
6 We recommended the Veterans Integrated Service Network 16 Director conduct a scheduling audit within 3 months after Recommendations 3 through 5 are implemented to ensure the corrective actions taken were effective.
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| 15-03700-283 | Review of VA's Guidance on Protecting Religious Beliefs | Audit | ||
1 We recommended the Interim Under Secretary for Memorial Affairs rescind and replace Chapters 6 and 7 from Manual 40-2, National Cemeteries, Administration, Operation, and Maintenance.
Closure Date:
2 We recommended the Interim Under Secretary for Memorial Affairs recertify or rescind Directive 3170/1, Ceremonies and Special Events at VA National Cemeteries.
Closure Date:
3 We recommended the Interim Under Secretary for Memorial Affairs incorporate National Cemetery Administration’s three interim guidance documents into directives or handbooks.
Closure Date:
4 We recommended the Interim Under Secretary for Memorial Affairs develop mechanisms to ensure staff begin the process of updating guidance and compensate for the time needed to draft guidance and obtain staff concurrence.
Closure Date:
5 We recommended the Under Secretary for Health recertify or rescind Veterans Health Administration’s three religious belief guidance documents that need to be updated.
Closure Date:
6 We recommended the Under Secretary for Health develop mechanisms to ensure staff begin the process of updating guidance and compensate for the time needed to draft guidance and obtain staff concurrence.
Closure Date:
7 We recommended the Under Secretary for Health provide staff a means to request senior official assistance, when necessary, to obtain timely agency-level concurrences.
Closure Date:
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| 16-00118-321 | Combined Assessment Program Review of the Amarillo VA Health Care System, Amarillo, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility set triggers for when a Focused Professional Practice Evaluation for cause would be indicated.
Closure Date:
2 We recommended that facility clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee and that facility managers monitor compliance.
Closure Date:
3 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:
4 We recommended that designated employees follow the facility policy for identification of individuals entering the facility after normal business hours and that facility managers monitor compliance.
Closure Date:
5 We recommended that facility managers ensure medical waste/biohazard containers are properly secured and monitor compliance.
Closure Date:
6 We recommended that facility managers ensure employees perform and consistently document monthly cleaning of walls and light fixtures in all compounding areas and monitor compliance.
Closure Date:
7 We recommended that sending nurses document transfer assessments and that facility managers monitor compliance.
Closure Date:
8 We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
Closure Date:
9 We recommended that clinicians include contact numbers of family or friends for support and an assessment of available lethal means and how to keep the environment safe in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Closure Date:
10 We recommended that treatment teams review patients’ high-risk flags at least every 90 days and that facility managers monitor compliance.
Closure Date:
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| 16-00027-318 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Connecticut Healthcare System, West Haven, Connecticut | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Facility Director ensures that fire drills and fire drill critiques are conducted at least every 12 months at the Winsted VA Clinic.
Closure Date:
2 We recommended that the Winsted VA Clinic manager ensures that the information technology server closet is maintained according to information technology safety and security standards.
Closure Date:
3 We recommended that providers sign Home Telehealth assessments and treatment plans.
Closure Date:
4 We recommended that the Facility Director ensures that the facility's written policy for the communication of laboratory results includes all required elements.
Closure Date:
5 We recommended that clinicians consistently notify patients of their laboratory results as required by VHA.
Closure Date:
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| 16-00029-322 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Jesse Brown VA Medical Center, Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility revise the local policy to include specific procedures for the identification of individuals entering the CBOCs.
Closure Date:
2 We recommended that the facility ensure a safe work
environment with adequate security coverage and incident responses at the Auburn Gresham VA Clinic.
Closure Date:
3 We recommend that the facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
Closure Date:
4 We recommended that clinicians consistently notify patients of their laboratory results as required by VHA.
Closure Date:
5 We recommended that the facility update its template to ensure providers’ plans of care and disposition are accurately documented for patients with positive PTSD screens.
Closure Date:
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| 16-00121-320 | Combined Assessment Program Review of the Jesse Brown VA Medical Center, Chicago, Illinois | 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 clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
Closure Date:
3 We recommended that the facility revise the policy and protocol for the identification of individuals entering the facility to include specialty/restricted areas and instructions regarding visitors who enter the facility during business hours and that facility managers monitor compliance.
Closure Date:
4 We recommended that facility managers ensure an emergency eyewash station is readily accessible to the chemotherapy compounding area where employees compound hazardous medications.
Closure Date:
5 We recommended that employees wear personal protective equipment and gloves when compounding sterile products in the operating room satellite pharmacy and that facility managers monitor compliance.
Closure Date:
6 We recommended that sending nurses document transfer assessments and receiving nurses document transfer notes and that facility managers monitor compliance.
Closure Date:
7 We recommended that attending physicians co-sign resident physicians’ discharge notes/instructions and that facility managers monitor compliance.
Closure Date:
8 We recommended that the facility review and revise its advance directives policy to ensure it is consistent with Veterans Health Administration policy.
Closure Date:
9 We recommended that the facility implement a plan for transition to the allowed note titles and that facility managers monitor compliance.
Closure Date:
10 We recommended that employees screen inpatients to determine whether they have advance directives and document the screening and that facility managers monitor compliance.
Closure Date:
11 We recommended that employees consistently use appropriate note titles to document screening and that facility managers monitor compliance.
Closure Date:
12 We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
Closure Date:
13 We recommended that clinicians consistently place flags in the electronic health records of high-risk patients and that facility managers monitor compliance.
Closure Date:
14 We recommended that clinicians develop Suicide Prevention Safety Plans during the admission for all patients identified as high risk and that plans include contact numbers of family or friends for support and assessment of available lethal means and how to keep the environment safe and that facility managers monitor compliance.
Closure Date:
15 We recommended that clinicians perform and document patient assessments following blood product transfusions and that facility managers monitor compliance.
Closure Date:
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| 14-03183-317 | Healthcare Inspection - Alleged Patient Safety Concerns, Miami VA Healthcare System, Miami, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that Community Living Center patients, families, and staff know the circumstances and guidelines under which they should initiate Integrated Ethics consults, have access to the Ethics Consultation Service, and know how to request an ethics consultation.
2 We recommended that the System Director ensure that Community Living Center staff receive training regarding suicide risk factors and the importance of documenting and communicating identified suicide risk factors during Interdisciplinary Team meetings.
3 We recommended that the System Director ensure that system clinical leadership reviews current practices of the ordering and administration of sleeping medications in the Community Living Center to determine if those practices optimize patient safety.
4 We recommended that the System Director ensure that reviews of incidents involving patient safety are comprehensive and accurately reflect and document all components as outlined in the VHA National Patient Safety Improvement Handbook guidelines.
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