Federal Reports

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

Should same-day delivery remain a niche product mostly appealing to urban Millennials, next-day delivery could instead become the “new normal” for many online orders. As it keeps one eye on the future of same-day delivery, the Postal Service should also continue to focus on next-day delivery through flagship offerings such as Parcel Select Destination Delivery Unit (DDU). Failing to do so could jeopardize the long-term viability of its unmatched last-mile network.

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

A Reservation Sales Agent based in Philadelphia was terminated from employment on December 23, 2019, for submitting falsified medical documentation to extend her medical leave of absence. She had previously entered into an Alternative Resolution Dispute agreement on November 4, 2019, with the Magisterial District in Bucks County, Commonwealth of Pennsylvania, and received 12 months’ probation, 10 hours community service, and was directed to pay restitution of $228 to Amtrak.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to access care coordination for a patient who died by suicide while admitted to an inpatient medicine unit at the facility. The patient was assessed as heightened but not imminent risk for suicide. Facility Emergency Department staff failed to report the patient’s suicidal ideation to the facility's Suicide Prevention Coordinator. Two consulting staff members and an inpatient registered nurse completed required suicide prevention training but failed to involve clinicians when the patient verbalized suicidal thoughts and warning signs. Two of the three staff documented the patient’s suicidal thoughts and warning signs in consult results notes, but the OIG did not find documentation that the inpatient medicine resident reviewed or acted on the consult results. During an internal review, the facility’s root cause analysis team did not interview staff members involved in the patient’s care. The internal review team identified many lessons learned for which the Veterans Health Administration (VHA) does not require action items. VHA does not provide written guidance on the identification of lessons learned, related action expectations, and how to distinguish lessons learned from root causes. The absence of formal guidance may have contributed to the team’s failure to identify critical actions in the prevention of adverse patient events. Facility leaders did not make an institutional disclosure to the patient’s next of kin. The Patient Safety Committee and the Quality Management Council meeting minutes did not document deliberations and track actions to resolution. The OIG made a recommendation to the Under Secretary for Health related to written guidance for lessons learned, and six recommendations to the Facility Director related to Suicide Prevention Coordinator notification, a review of the patient’s care, consult results, institutional disclosure, the root cause analysis process, and documentation of meeting minutes.