Federal Reports

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at Edith Nourse Rogers Memorial Veterans Hospital (the facility), covering leadership, organizational risks, and key 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 leaders had been working together for approximately 15 months. Selected employee satisfaction results indicated general satisfaction with facility leaders, but opportunities exist to improve workplace attitudes. Leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center metrics but should continue to act to sustain and improve performance measures contributing to the SAIL “5-star” and community living center “2-star” quality ratings. The OIG issued 21 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data • Root cause analysis processes (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (3) Environment of Care • Environmental safety and cleanliness • Medical supply storage • Panic alarm testing • Comprehensive emergency management plan (4) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • Military sexual trauma training (5) Geriatric Care: Antidepressant Use among the Elderly • Justification for medication initiation • Patient and/or caregiver education and evaluation of understanding • Medication reconciliation processes (6) Women Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership (7) High-Risk Processes: Emergency Department and Urgent Care Center Operations • 24-hour Urgent Care Center operations waiver • Appointed Urgent Care Center medical director • Urgent Care Center staffing • Urgent Care Center support services availability

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care at the VA Central Western Massachusetts Healthcare System, covering leadership, organizational risks, and key 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 team appeared relatively stable, having worked together for 18 months at the time of the inspection. Employee and patient satisfaction scores were better than the VHA average, with some opportunity for improvement. The facility received preliminary denial, but later full accreditation from The Joint Commission. The facility’s accreditation findings, sentinel events, and disclosures identified areas for improvement. The leadership team was knowledgeable of Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics and should continue to act to sustain and improve performance of measures contributing to the SAIL “5-star” and CLC “3-star” quality ratings. The OIG issued 30 recommendations for improvement: (1) Quality, Safety, and Value • Peer review process • Utilization management process • Root cause analysis • Annual patient safety report (2) Medical Staff Privileging • Professional practice evaluations (3) Environment of Care • Environmental cleanliness and safety (4) Medication Management • Controlled substances inspectors’ appointments • Controlled substances inspections • Medication override process (5) Mental Health • Military Sexual Trauma training (6) Geriatric Care • Patient/caregiver education • Medication reconciliation (7) Women’s Health • Women Veterans Health Committee processes • Cervical cancer data tracking • Abnormal results notification (8) High-Risk Processes • 24-hour operations waiver • Staffing and call schedules • Services, equipment, and supply availability • Patient flow metrics • Directional signage • Psychiatric intervention room

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