This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Chalmers P. Wylie Ambulatory Care Center covering leadership and organizational risks and key 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 facility’s executive leadership had been working together for about nine months. Employee satisfaction and patient experience scores were similar to or better than the VHA average. Organizational leaders appeared to support efforts related to safety and quality care; however, there were concerns related to wrong-site /wrong-procedures and appropriate and timely institutional disclosures. The leaders were knowledgeable of Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to take actions to improve performance of measures contributing to the current SAIL ratings. The OIG issued 13 recommendations for improvement in the following areas: (1) Quality, Safety, and Value • Implementation of peer review improvement actions • Completion of Root Cause Analyses • Committee review of resuscitative episodes (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes • Medical Executive Board consideration of OPPEs in recommendation to continue privileges (3) Controlled Substances Inspections • Quarterly review of controlled substances inspections reports (4) Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (5) Antidepressant Use among the Elderly • Patient/caregiver education on medications • Medication reconciliation (6) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee core membership • Abnormal results notification (7) Incidental • Anesthesia documentation of controlled substance administration
Columbus, OH
United States
