Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: MONDAY, October 25, 1993 TAG: 9310250042
SECTION: VIRGINIA PAGE: A-1 EDITION: METRO
SOURCE: LESLIE TAYLOR STAFF WRITER
DATELINE: LENGTH: Long
A General Accounting Office report to be released today by Sen. Charles Robb, D-Va. - who requested the GAO probe at the peak of last year's medical center controversy - lauds Director John Presley for restoring staff and public confidence in the facility's management and for addressing quality-of-care issues.
But the GAO tempered the praise with findings that:
Nurse staffing shortages continue.
Medical records are incomplete.
Some psychiatrists are not seeing their patients regularly.
Certain psychiatrists and nurses are not performing essential functions, such as taking patients' histories upon admission, assessing patient needs and providing discharge planning before a patient is released.
"These problems are resulting in poor-quality care for some patients," the GAO reported.
Robb called for a GAO investigation in April of last year into union claims that low employee morale, staffing shortages and mismanagement had led to poor patient care. Robb's call followed the discovery of two patients' bodies on medical center grounds, which fueled union charges. (A third body was found in May.)
The GAO's full-scale investigation began two months later, after it conducted a preliminary review of managerial issues and how they carried over into the medical center's quality of care.
The final report was completed a month ago. Robb had 30 days from its Sept. 23 issue date to release its contents before the GAO made it available to the public.
"It's a good news, bad news report," Robb said in a news release. "While it outlines some of the improvements made in the past year, it also lays out in startling detail the amount of work we have to do to bring the facility up to par."
But Presley says the report does not give a current enough portrayal of medical center improvements.
The center last month received full accreditation from the Joint Commission on Accreditation of Healthcare Organizations, "considered to be the highest seal of approval a hospital can receive," Presley said. The report, however, refers to nursing care in seven medical center inpatient units as failing to meet the commission's accrediting criteria.
The GAO "came during our worst part," he said Sunday. "But we are a public institution and Senator Robb did call for this investigation."
The GAO met with more than 160 doctors, nurses, support staff, patients, management and families of patients in conducting its investigation.
Said Robb, "The report offers some disturbing specifics."
Robb said he was most troubled by examples of patient neglect, particularly in the center's psychiatric units. Nearly half of the medical center's inpatients are there for psychiatric care.
The GAO found that in two short-term acute-care psychiatric units, psychiatrists were not assessing patients' physical and psychological status on admission. Patients also had no treatment plans, ongoing evaluations or discharge planning.
A review of 10 patient records, selected at random, showed that three did not have notations of circumstances leading to their admission; eight did not contain a relevant social history or any data from the patient's family; nine did not contain progress notes indicating patient response to treatment; and none cited any short- or long-term treatment goals.
The report contained the following observation:
"We noted in a patient record that the nursing staff found that a female patient had a breast mass. A mammogram was ordered by the psychiatrist and performed in mid-August 1992 at a local hospital. The record indicates that over the next two months, the patient often screamed, cried and expressed fears that she was going to die from cancer. During our review of the patient's record in mid-October 1992, we noted that the mammography results had not been obtained. We provided this information to the nursing staff and the new unit psychiatrist. Until we took this action, no one had reviewed the progress notes to determine [1] if the patient's concerns had any basis in reality and [2] the findings of the mammography."
Robb said he was concerned "that these psychiatric patients - arguably the most disenfranchised group of veterans - have not been receiving proper care."
Robb said he is considering legislation to provide patients in veterans' hospitals the same rights and benefits as patients in other public hospitals. The center is, however, addressing performance problems and is hiring additional psychiatrists for these units, the GAO reported.
The GAO's review of patient records, interviews with nurses and patients and general observations on patient units "revealed continuing problems in patient assessment, nursing diagnosis, treatment care plans, intervention and evaluation," it reported.
Of 20 psychiatric patient records the GAO reviewed, none had complete nursing assessments, 11 did not contain a plan to meet the patients' nursing needs, and 14 did not record patient response to nursing interventions.
Most patients on these units were not receiving a complete medical history, physical examination, diagnostic testing or treatment for symptoms that led to their admission to the medical center, the GAO reported.
Though the GAO attributed the situation primarily to chronic staffing shortages over the past several years, it also attributed problems to findings that many nursing staff were not complying with nursing standards and criteria when providing patient care.
"Some nurses indicated that they did not have sufficient time to adhere to applicable nursing standards, while others said they believe additional in-service education is needed," the GAO reported.
The GAO strongly advised the medical center to improve its quality assurance program. Every VA hospital is required to have such a program - through which patient care is monitored and evaluated - in place.
The GAO found that quality assurance activities at the medical center were not adequately documented.
The GAO also identified problems that were not being identified by quality assurance personnel, such as a lack of written justification for restraints - usually leather arm or leg straps or a waist belt to temporarily prevent patients from harming themselves - a lack of treatment plans and a failure to provide therapy to psychiatric patients.
The GAO also looked at autopsies as part of its investigation into quality assurance. The autopsies, the GAO reported, provided quality assurance personnel with an indicator of the quality of care being provided at the facility.
But between 1991 and 1992, the rate of autopsies performed at the medical center declined significantly, the GAO reported. An interim chief of staff had expressed concern to the GAO about the decline but was not sure why the rate went down. He told the GAO that the medical center laboratory had sufficient resources to perform many more autopsies.
The GAO faulted prior administration - former Director Clark Graninger and former Chief of Staff Larry Edwards - for their failure to develop an effective center-wide quality assurance program. The GAO also cited an inadequately staffed and trained quality assurance group and hospital staff who have been "unresponsive in complying with requirements to fully document the care being provided to the facility's patients."
A government employee union had accused Graninger and Edwards of mismanagement and blamed them in part for causing employee morale to plummet. In an interview with the GAO, Graninger conceded that changes he tried to implement may have been too much too fast for the staff to grasp efficiently.
Both former administrators, the GAO concluded, viewed their appointments as a mandate for implementing change.
"Thus, they aggressively pursued their initiatives and viewed staff resistance as unnecessary delaying tactics and an indication that they had to press the staff even harder," the GAO reported.
Graninger was removed from his position as director in April of last year. Edwards was fired five months later.
"I think at one point you have to give credence to their criticism," Presley said of the GAO's findings. "But at this point, we've improved to the extent that we now have accreditation [by the Joint Commission on Accreditation of Healthcare Organizations] for three years. This is always going to be a challenge as we try to balance the therapeutic milieu with control. Quite frankly, I think we've found that balance."
Robb said he intends to ask the GAO to return to the Salem medical center within the year to re-evaluate progress. The GAO has recommended that Secretary of Veterans Affairs Jesse Brown direct the VA's undersecretary for health to require Presley to:
Review the psychiatric care at the medical center and take necessary action to ensure that it meets medical center bylaws.
Identify the educational needs of the nursing staff and implement in-service education programs.
Adequately staff the quality assurance office and require that its findings be reviewed and analyzed.
Require service chiefs to enforce requirements calling for complete and accurate medical records.
Recent staff changes - including the appointment of Presley and Chief of Staff Rajiv Jain - "represent movement in the right direction," the GAO reported.
"However, continued strong medical center management support is critical to the success of the program to identify and correct future problems."
by CNB