VA Health Care:

Labor Management and Quality-of-Care Issues at the Salem VA Medical Center

HRD-93-108: Published: Sep 23, 1993. Publicly Released: Oct 25, 1993.

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Pursuant to a congressional request, GAO reviewed management issues at the Department of Veterans Affairs' (VA) Medical Center in Salem, Virginia, focusing on how to: (1) restore confidence in the Center; and (2) ensure that high-quality patient services are provided.

GAO found that: (1) new management initiatives and the appointment of a new medical center director have improved the medical center's work environment, restored staff and public confidence in the management of the facility, and begun to address quality-of-care issues; (2) although the new medical center director has resolved many labor-management issues and is attempting to reduce nurse staffing shortages, nurse staffing shortages continue; (3) medical records are incomplete; (4) staff psychiatrists are not conducting regular exams or performing other essential functions; (5) the center's quality assurance program needs improvement because staffing and records management problems continue and result in poor-quality care for some patients; and (6) management should ensure that the quality assurance program objectively and systematically monitors and improves the quality and appropriateness of the services delivered.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: VA stated that significant actions to improve the psychiatric care being provided at the Salem VA Medical Center include approval of a 4-year Psychiatry/University of Virginia Residency Program designed to attract outstanding physicians and the addition of 2.5 full-time-employee-equivalents to the ceiling for psychiatry physicians. The psychiatry staff of 17.5 physicians include 5 chief resident graduates, 4 either double board certified or double board eligible in medicine and psychiatry and other staff with expertise in geriatric psychiatry, addictionology, sleep disorders, social work, and nursing. New physician orientation has been enhanced to include assessment of patients' progress notes, interdisciplinary treatment plans, and patient discharges. Increased emphasis has been placed on coordinating activities and groups, reinforcing requirements for complete and accurate medical records, peer reviews, and monitoring treatment plans.

    Recommendation: The Secretary of Veterans Affairs should direct the VA Under Secretary for Health to require the Salem Medical Center Director to review the psychiatric care being provided at the facility and take the necessary actions to ensure that it meets medical center bylaws.

    Agency Affected: Department of Veterans Affairs

  2. Status: Closed - Implemented

    Comments: VA stated that in April 1993, the Salem VA Medical Center developed and implemented written standards of practice and criteria for evaluating patient care. In September 1993, the medical center conducted a needs assessment and provided off-station training for 62 staff members. In October 1993, the center scheduled 21 on-station continuing education events. The medical center currently evaluates the nursing process on a quarterly basis and implements therapeutic patient groups as an ongoing process and as patient needs change.

    Recommendation: The Secretary of Veterans Affairs should direct the VA Under Secretary for Health to require the Salem Medical Center Director to identify the learning needs of the nursing staff and implement in-service education programs to reinforce the need to comply with nursing standards and criteria.

    Agency Affected: Department of Veterans Affairs

  3. Status: Closed - Implemented

    Comments: VA reported that the Salem VA Medical Center hired a qualified Quality Management Coordinator and structured the quality management office with appropriate staff assignments including an Inection Control Nurse and a qualified Risk Manager. Within approximately 15 months, the number of staff in the center's quality assurance office increased from 5 to 15. The medical center has developed a quality management resources manual, implemented a quality management plan, established a quality improvement board, and implemented a quality improvement profile for credentialing and priviledging. There are also regular reviews of quality management findings at the same level, the quality improvement board, and appropriate executive committees.

    Recommendation: The Secretary of Veterans Affairs should direct the VA Under Secretary for Health to require the Salem Medical Center Director to adequately staff the quality assurance office and require that quality assurance findings developed by the office be reviewed and analyzed on a center-wide basis.

    Agency Affected: Department of Veterans Affairs

  4. Status: Closed - Implemented

    Comments: The Chief of Staff at the Salem VA Medical Center has developed a plan on enforcing requirements for complete medical records and reinforced this emphasis by acquiring new transcription equipment and contracting for outside transcription services. The medical center has also established a task force to resolve other medical record issues.

    Recommendation: The Secretary of Veterans Affairs should direct the VA Under Secretary for Health to require the Salem Medical Center Director to require service chiefs to enforce requirements calling for complete and accurate medical records.

    Agency Affected: Department of Veterans Affairs

 

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