This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the Southeast Louisiana Veterans Health Care System, covering leadership and organizational risks and key processes associated with promoting quality care. 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 leadership team appeared relatively stable, having worked together for seven months at the time of the inspection. Selected survey scores indicated that employees and patients were generally satisfied. Review of accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. The leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics, but should continue to take actions to improve performance of measures contributing to the SAIL “3-star” quality rating. The new CLC had not been assigned a quality star rating as of December 31, 2018. The OIG issued 17 recommendations for improvement: (1) Quality, Safety, and Value • Review of utilization management data • Resuscitation episode reviews • Code responder training (2) Medical Staff Privileging • Ongoing and focused professional practice evaluation processes (3) Environment of Care • Medication safety (4) Military Sexual Trauma (MST) Follow-up and Staff Training • MST mandatory training (5) Antidepressant Use among the Elderly • Patient/caregiver education • Medication reconciliation (6) Abnormal Cervical Pathology Results Notification and Follow-up • Full-time women veterans program manager • Women Veterans Health Committee membership and reporting process • Cervical cancer screening data tracking • Patient notification of abnormal results (7) Emergency Departments and Urgent Care Center Operations • Emergency department backup call schedule
New Orleans, LA
United States
