by Matt Rosenberg April 13th, 2012
A new oversight report from the U.S. Department of Veterans Affairs Office of the Inspector General (OIG) identifies problems with sedation safety, colorectal cancer screening, sanitation, medication management, coordination of care, quality assurance and patient satisfaction at the VA’s Puget Sound Health Care System-Seattle, for vets who’ve served in Iraq, Afghanistan and elsewhere. The audit covers a look into quality of care at just the system’s hospital complex on Columbian Way in Seattle’s Beacon Hill neighborhood, and the VA Hospital at American Lakes in Lakewood, Wash., near Tacoma – but not its additional seven Western Washington clinics, confirmed a VA OIG official in Washington, D.C. VA Puget Sound Seattle calls itself “the primary referral site for the VA’s Northwest Region” serving 80,000 veterans in several states. Care is provided in collaboration with physicians of the University of Washington’s UW Medicine unit.
Colorectal cancer screening, treatment concerns
Based on inspections in late January, 2012 and covering a period extending back two years at VA Puget Sound-Seattle’s two main hospitals, the report found that in one quarter of patient screenings for colorectal cancer that were checked, the facility couldn’t document that the patients were notified of the results within the required 14 days. Additionally in a sample of cases checked for patients who screened positive for colorectal cancer, there were no follow-up health care plans developed within the required timeline, and more than half of positive screenees didn’t get needed further diagnostic testing within the required 60 days. In half of patient biopsy cases checked there was no documentation of results notification within the required 14 days.
These types of safeguards were developed after a 2006 nationwide report raised concerns about gaps for VA patients of three to six months between initial positive screenings for colorectal cancer and further diagnosis, John D. Daigh, Jr., M.D., Assistant Inspector General for Healthcare Inspections for the U.S. Veterans Administration, in Washington, D.C., told Public Data Ferret today. In the more recent Puget Sound cases patients were eventually notified of their test results and no one’s health suffered as a result of lateness, but timely notification and adherence to the safeguards remains important, he added. The 2006 report was based on information from VA facilities in 20 metro regions, including Puget Sound.
“Moderate sedation” safety checks ignored
The new audit for VA Puget Sound-Seattle also found that safety procedures for so-called “moderate sedation” were lacking. In more than half of those sedation cases checked, there was no indication of full patient assessment for risk factors such as substance use or abuse, or airway blockage, and also no indications – in more than half the cases reviewed – of a required “timeout” for pre-procedure assessment by the provider.
Sanitation and security controls lax
Looking at the “environment of care” at multiple units in the Seattle VA hospital, the audit team three times fund that special rooms used to contain and control human waste products, so called “soiled utility rooms” – were unlocked, violating regulations meant to control risk of spreading bacteria, viruses and fungi. For patients in the Mental Health Residential Rehabilitation Treatment Program at the Seattle and American Lakes hospitals, “elopement prevention” systems meant to meant to keep residents from leaving without authorization and therefore possibly endangering their safety and well being, were not checked for functionality daily, as required.
Problems with vaccine screening, patient hand-offs
Medication management concerns were also raised in the report. For patients who should have been screened for tetanus vaccinations at certain points in care, such as prior to joining a community living center, or at clinic visits, records showed more than half were not screened. Investigators also reported problems in coordination of care. Records of 18 heart failure patients were examined and those of more than one-third lacked the name of a clinical provider who would be be providing follow-up care. Such “hand-off communication” is considered important to continuity of care and patient welfare.
“Quality management” challenges
Investigators also identified several “quality management” issues. In nearly half the cases examined for oversight of newly-hired licensed independent health care providers, required focused evaluations on their professional practices had not been performed. In addition, although resuscitations require multidisciplinary team review afterward to assess whether best practices were employed, the reviews were being done not by a team, but by an individual clinician. As well, though the hospital’s Peer Review Committee meeting minutes are supposed to indicate that corrective steps have been taken to resolve targeted “quality management” issues in patient care, in seven of 11 instances probed for 2011, there was no such documentation evident.
VA Puget Sound response
In a response appended to the report, David A. Elizade, Director of the VA Puget Sound Health Care System in Seattle, concurred with all the findings and specified steps that had been or would soon be taken to correct the problems identified – with June 1, 2012 as the latest of the various target dates for completion.
VA patient satisfaction relatively low here vs. region, nation
In the VA OIG report, patient satisfaction surveys showed the Seattle VA hospital ranked markedly lower compared to others in the Northwest and nationwide, for inpatients and outpatients, in the most recent full fiscal year, 2011. Of those findings, Daigh, the VA’s Assistant Inspector General for Healthcare Inspections, said, “It’s important. It implies to me there is some room for improvement,”