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New Inspector's Report on Dorn VA Allegations

6:35 PM, Feb 6, 2014   |    comments
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Columbia, SC (WLTX) -- The Veteran's Affairs Office of Healthcare Inspections released a report citing deficiencies and including recommendations for the Dorn VA Medical Center Thursday.

The VA's Office of Healthcare Inspections reviewed allegations of the quality of care Midlands Veterans have received at the William Jennings Bryan Dorn VA Medical Center.

The Inspection report states they could not substantiate the following claims:

  • Higher complications from surgery in the facility
  • Patients held under extended anesthesia for training purposes
  • A power outage had no impact on surgical patients

Among some of the findings of the Inspector's report, it was confirmed that the following claims were true:

  • Surgical staffing and scheduling processes had direct impact on delays of surgeries and overtime expenses
  • Improper use of logbooks for patient records
  • Insufficient staffing in the Dorn surgery clinic
  • Inconsistencies in the facility's Infection Control program
  • Poor record keeping among many of the facility's committees
  • Facility Quality Management program not properly overseen
  • Facility's Patient Safety program and Peer Review program not in compliance with VHA requirements
  • Many key Facility leaders were only in "Acting" capacities

The Office of Healthcare Inspector has made the following recommendations to the Dorn VA Medical Center: (direct copy)

  1. We recommended that the VISN Director take action to ensure more permanent, stable leadership in key positions.
  2. We recommended that the Facility Director ensure that morbidity outliers are discussed and analyzed, and that corrective actions are taken as indicated.
  3. We recommended that the Facility Director ensure that residents and staff discontinue use of logbooks and utilize approved electronic methods to track and schedule surgical cases.
  4. We recommended that the Facility Director ensure adequate staffing and processes to minimize operating room delays and meet patient care needs.
  5. We recommended that the Facility Director ensure that infection control surveillance data is analyzed and trended, and that Infection Control Sub-Council minutes include required elements and reflect preventive and corrective measures.
  6. We recommended that the Facility Director ensure compliance with VHA guidance regarding identification, reporting, and follow-up of reusable medical equipment reprocessing issues, and that Reusable Medical Equipment committee minutes reflect these and other required elements.
  7. We recommended that the Facility Director improve Supply Processing Services processes to ensure staff are trained and competent in relevant reusable medical equipment reprocessing activities, and that competencies, manufacturer instructions, and standard operating procedures are consistent.
  8. We recommended that the Facility Director ensure that Quality Management oversight and reporting structures are fully integrated, comprehensive, and functional.
  9. We recommended that the Facility Director ensure oversight and subordinate committee minutes include required elements; and reflect data analysis, conclusions, action tracking and follow-up, and outcome measurement.
  10. We recommended that the Facility Director ensure compliance with patient safety program reporting and evaluation policies, and ensure that reportable close calls are clearly defined in local policy.
  11. We recommended that the Facility Director ensure compliance with VHA policies on identification and reporting of cases for peer review, including use of the Occurrence Screening package.
  12. We recommended that the Facility Director ensure the Peer Review Committee complies in a timely manner with VHA guidelines regarding discussion, analysis, tracking, and follow-up of final Peer Review Committee decisions. 

In the Inspector's report, full responses addressing each of the recommendations above, including target completion dates, and implementation of programs are included.

Download the full report

So what do all of these recommendations mean for Midlands Veterans needing surgical services at the Dorn VA?

As the Dorn Administrators detail in their responses on the report, upon completion between now and the end of March, 2014, it reads as though the surgical scheduling has already begun rolling out, which means better scheduling for patients, and less wait-times for patients needing surgery. Also the Facility is working to fill open positions and work to update training of new employees.

Dorn says they also are implementing training in other areas, updating committee standards on multiple levels to address organization, records keeping, reporting, and follow-up.

Dorn will also review local policies concerning patient safety, and the reporting of patient 'close calls' in operating procedures, when a patient's life may have been at risk, and define local policy on reporting these incidents. 

 

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