Failures Related to the Care and Discharge of a Patient and Leaders’ Response at the VA New Mexico Healthcare System in Albuquerque

The VA New Mexico Healthcare System Director reviews the ineffective communication, collaboration, and utilization of available sources of information by social work staff and the enrollment and eligibility supervisor and ensures the ongoing assessment of barriers that could affect patients care.

The VA New Mexico Healthcare System Director educates emergency department providers on the expectation for identifying the eligibility of each patient who requires admission and the need to obtain Chief of Staff approval if an ineligible patient necessitates care at the facility.

The VA New Mexico Healthcare System Director reviews the process for note retractions and ensures providers and document specialists are trained on the process.

The VA New Mexico Healthcare System Director monitors compliance with the requirement that discharge paperwork is provided to each patient who is discharged.

The VA New Mexico Healthcare System Director evaluates that staff (inpatient social workers, providers, transfer coordinators, nurses, and the nursing officer of the day) are aware that ineligible patients can be transported from the facility and provides education related to the processes required for approval and facilitation of the transport.

The VA New Mexico Healthcare System Director reviews the facilitys root cause analysis process, ensures that staff directly involved in an adverse event do not participate in root cause analysis of an event, and considers if another root cause analysis should be completed on this event.

The VA New Mexico Healthcare System Director takes action to ensure that leaders understand and effectively utilize high reliability organization principles noted in this report to identify and correct deficiencies.

The VA New Mexico Healthcare System Director ensures that social work staff are knowledgeable that 10-10EZR forms can be completed at any time to correct a patients financial information and documents are not required to verify financial information.

The VA New Mexico Healthcare System Director identifies why postsurgical follow-up care was not coordinated for the patient and takes action as warranted.

The VA New Mexico Healthcare System Director ensures that providers communicate relevant information to community healthcare providers as needed to ensure continuity of care.