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Management Challenges – Fiscal Year 2019

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Canandaigua VA Medical Center, covering leadership and organizational risks and key clinical and administrative 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 facility’s executive leaders were all permanently assigned for seven months prior to the OIG’s inspection and seemed actively engaged with employees and patients. Review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. The OIG noted continuing challenges regarding the facility’s integration with the Bath VA Medical Center to form the VA Finger Lakes Healthcare System. The leadership team were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics, but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “4-star” and CLC “5-star” quality ratings. The OIG issued 14 recommendations for improvement: (1) Environment of Care • Medical equipment storage • Panic alarm testing • Environmental safety and repair • Patient information protection (2) Controlled Substances Inspections • Reconciliation of one-day’s dispensing and order verification • Controlled substances coordinator maintaining oversight (and refrain from conducting routine inspections) • Verification of hard copy prescriptions (3) Military Sexual Trauma (MST) Follow-up and Staff Training • MST coordinator responsibilities • MST mandatory training (4) Antidepressant Use among the Elderly • Education and evaluation of the education provided • Medication reconciliation (5) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership