This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the VA Western New York Healthcare System covering 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 executive leadership team was generally stable, despite the assistant director also serving as the acting associate director. Employee satisfaction and patient experiences in the inpatient care setting were worse than VHA. The leaders should review steps to identify cases that may need institutional disclosures and evaluate the process of identifying improvement opportunities. Executive leadership team members were knowledgeable about Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics and the actions necessary to sustain and improve performance that contribute to the SAIL “4-star” quality ratings. The OIG issued 18 recommendations for improvement: (1) Quality, Safety, and Value • Basic or advanced cardiac life support certification for resuscitation staff (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes • Required review and evaluation of privileging requests (3) Environment of Care • Environmental cleanliness • Mental health seclusion room safety • Review of inventory of assets and resources (4) Medication Management • Review of balance adjustments • Controlled substance inventories (5) Mental Health • Military Sexual Trauma training (6) Geriatric Care • Patient/caregiver education • Medication reconciliation (7) Women’s Health • Full-time women veterans program manager • Women Veterans Health Committee membership and quarterly meetings (8) Emergency Departments and Urgent Care Center Operations • Licensed provider staffing • Equipment/supplies to treat sexual assault patients
Buffalo, NY
United States
