Combined Assessment Program Review of the James A. Haley ...
Department of Veterans Affairs Office of Inspector General
Office of Healthcare Inspections Report No. 15-04709-208
Combined Assessment Program
Review of the
James A. Haley Veterans' Hospital
Tampa, Florida
March 23, 2016
Washington, DC 20420
To Report Suspected Wrongdoing in VA Programs and Operations Telephone: 1-800-488-8244 E-Mail: vaoighotline@
(Hotline Information: oig/hotline)
AD CAP CSP CT EHR EOC facility FY MH NA NM OIG OR QSV RRTP VHA
CAP Review of the James A. Haley Veterans' Hospital, Tampa, FL
Glossary
advance directive Combined Assessment Program compounded sterile product computed tomography electronic health record environment of care James A. Haley Veterans' Hospital fiscal year mental health not applicable not met Office of Inspector General operating room quality, safety, and value residential rehabilitation treatment program Veterans Health Administration
VA OIG Office of Healthcare Inspections
CAP Review of the James A. Haley Veterans' Hospital, Tampa, FL
Table of Contents
Page
Executive Summary ................................................................................................... i
Objectives and Scope ................................................................................................ 1
Objectives ............................................................................................................... 1
Scope...................................................................................................................... 1
Reported Accomplishment........................................................................................ 2
Results and Recommendations ................................................................................ 3
QSV ........................................................................................................................ 3
EOC ........................................................................................................................ 6
Medication Management......................................................................................... 9
Coordination of Care............................................................................................... 12
CT Radiation Monitoring ......................................................................................... 15
ADs ......................................................................................................................... 17
Suicide Prevention Program ................................................................................... 18
MH RRTP ............................................................................................................... 20
Appendixes A. Facility Profile .................................................................................................... 22
B. Strategic Analytics for Improvement and Learning (SAIL) ................................. 23
C. Acting Veterans Integrated Service Network Director Comments ..................... 26
D. Facility Director Comments ............................................................................... 27
E. Office of Inspector General Contact and Staff Acknowledgments ..................... 30
F. Report Distribution ............................................................................................. 31
G. Endnotes ........................................................................................................... 32
VA OIG Office of Healthcare Inspections
CAP Review of the James A. Haley Veterans' Hospital, Tampa, FL
Executive Summary
Review Purpose: The purpose of the review was to evaluate selected health
care facility operations, focusing on patient care quality and the environment of care, and to provide crime awareness briefings. We conducted the review the week of January 11, 2016.
Review Results: The review covered eight activities. We made no
recommendations in the following three activities:
Medication Management
Advance Directives
Mental Health Residential Rehabilitation Treatment Program
The facility's reported accomplishment was receiving the Get With The Guidelines?-Stroke Gold Plus Achievement Award.
Recommendations: We made recommendations in the following five activities:
Quality, Safety, and Value: Consistently review Ongoing Professional Practice Evaluation data every 6 months.
Environment of Care: Repair damaged equipment in patient care areas, or remove it from service. Replace missing/stained ceiling tiles.
Coordination of Care: Validate patient and/or caregiver understanding of the discharge instructions provided.
Computed Tomography Radiation Monitoring: Ensure all computed tomography technologists have documented training on safe procedures for operating the types of computed tomography equipment they use.
Suicide Prevention Program: Require that new employees complete suicide prevention training and that new clinical employees complete suicide risk management training within the required timeframe. Ensure patients and/or caregivers receive a copy of the Suicide Prevention Safety Plan.
Comments
The Acting Veterans Integrated Service Network Director and Facility Director agreed with the Combined Assessment Program review findings and recommendations and provided acceptable improvement plans. (See Appendixes C and D, pages 26?29, for
VA OIG Office of Healthcare Inspections
i
CAP Review of the James A. Haley Veterans' Hospital, Tampa, FL
the full text of the Directors' comments.) We consider recommendation 2 closed. We will follow up on the planned actions for the open recommendations until they are completed.
JOHN D. DAIGH, JR., M.D.
Assistant Inspector General for
Healthcare Inspections
VA OIG Office of Healthcare Inspections
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