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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