Federal Reports

Management of Select Service Contracts Used by the Office of Data and Technology (ODT) (September 11, 2019)

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the leadership performance and oversight by the Veterans Integrated Service Network (VISN) 4, 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; and Medication Management: Controlled Substances Inspections. The OIG conducted this unannounced visit while concurrent inspections of the following VISN 4 facilities were also performed—Coatesville VA Medical Center and VA Butler Healthcare. The VISN’s executive leadership team appeared stable, with the deputy director, chief medical officer, and quality management officer serving together for the past 16 months. Selected survey scores related to employee satisfaction were consistently better than VHA averages. The VISN averages for selected patient experience survey questions were similar to VHA averages. The VISN leaders appeared actively engaged with employees and patients and were working to sustain and further improve satisfaction. The VISN executive leaders seemed to support efforts to improve and maintain quality care. Review of access metrics and clinician vacancies did not identify any substantial organizational risk factors. The VISN leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center metrics and should continue to take actions to sustain and improve performance of measures contributing to the current SAIL ratings. The OIG issued two recommendations for improvement: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (2) Environment of Care • Establishment of a VISN emergency management committee

The VA Office of Inspector General (OIG) conducted a rapid response healthcare inspection to review staffing and access concerns at the Mann-Grandstaff VA Medical Center (facility), Spokane, Washington. Seven providers left the facility from early June through mid-July 2019; however, the OIG did not find the loss was unexpected or unusual. The provider losses were due to internal transfers, planned retirements, and resignations. The OIG found that access to some outpatient care started to decline around May 2019. As of August 2019, the percent of primary care new patient appointments completed less than 30 days from the created date decreased from more than 80 percent in April to less than 40 percent in August. The OIG team confirmed that the facility formed a multidisciplinary team to analyze the potential impact on patients, staff, and the facility at large, of closing the intensive care unit due to low utilization. As of late July 2019, the facility was temporarily utilizing one of its two operating rooms. The decision to curtail operating room utilization was the result of Sterile Processing Service staffing shortfalls and other deficiencies identified during a visit from the National Program Office for Sterile Processing (NPOSP). Facility leaders determined that a temporary reduction in operating room procedures and dental services to decrease the volume of items requiring sterile processing was in the best interest of patient safety. A dentist was functioning as the Acting Chief of Radiology. The previous Chief of Radiology voluntarily stepped down to fill a staff radiologist position. The Chief of Dental Service was detailed to the position of Acting Chief of Radiology based on previous leadership experience and qualifications. The OIG made two recommendations related to ensuring that patients have timely access to care and continued corrective actions regarding deficient areas identified in the NPOSP report.

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the Jonathan M. Wainwright Memorial VA Medical Center, covering leadership and 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; and Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up. The facility’s executive leaders had worked together for one month, with three of the four positions permanently assigned during the OIG visit. Three of four executive leaders’ employee satisfaction scores were generally similar to or better than VHA averages. Patient experience questions showed one score above and one below VHA averages. Facility leaders were engaged with employees and patients and working to improve engagement and satisfaction. Leaders supported efforts to improve and maintain patient safety, quality care, and other positive outcomes. Leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to take actions to improve performance contributing to the facility’s SAIL “2-star” quality rating. No substantial organizational risk factors were identified. The OIG issued 17 recommendations for improvement: (1) Medical Staff Privileging • Professional practice evaluation processes (2) Environment of Care • Patient information protection • Environmental safety • Inspections and testing processes (3) Medication Management: Controlled Substances Inspections • One-day’s dispensing reconciliation • Hard copy prescription verification (4) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • MST training • Communication with leadership • MST initial evaluations (5) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee processes • Patient notification of abnormal results

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