Report: White River VA Lapsed on Safety Protocols

Jun 21, 2017

An assessment of the quality of care provided to military veterans at the VA hospital in White River Junction, Vermont, has found that management and staff failed on numerous occasions to follow best practices to keep patients safe.

For example, patients under moderate sedation were not always released from the hospital in the care of a responsible adult. Documentation of whether patients were sufficiently screened before sedation was often missing, and their pain levels were not consistently monitored afterwards. In about half of observed cases, patients moving between facilities did not have the required written approval of their physician to do so.

These and other issues pertaining to oversight and data collection were outlined in a 52-page report released Tuesday. White River VA Medical Director Al Montoya joined NHPR’s Peter Biello to discuss the report.

In reading this report, many of the allegations boiled down to the same thing: failure to monitor on a regular basis whether caregivers at the hospital were checking the boxes and following protocol. Documentation was missing, and if tests were done before providing medication or before a procedure, they weren't logged. Why was the hospital not keeping closer watch and following procedures?

Yeah, so certainly, Peter, I appreciate you giving me the opportunity to talk about our OIG CAP [Office of the Inspector General Combined Assessment Program] assessment review. What we actually found, and the resounding theme from our review, which was actually conducted back in December, the resounding theme was really making sure that our documentation was on point and that attention to detail was being followed.

We have certainly learned from this opportunity. From the day that the Office of Inspector General left our facility, we started to work immediately on corrective actions.

But, why? Why was the hospital not keeping track more closely? Were you able to determine that?

I think, we’re looking at, across the organization we look at systemic or systematic things. Certainly what we’ve done is infuse process improvement or Lean Six Sigma methodology into the mix, I think it certainly provides that failsafe. Oftentimes around the facility what we see is that there’s one person who does it really well, but when that one person retires, they also leave with that wealth of knowledge.

Some of the things that we’re doing to improve is to make sure that there’s that wealth of knowledge across the organization, that there are failsafes built into place.

Certainly the report isn’t universally negative, and that’s not the image I want to present. It did, for example, compliment the partnerships you made with University of Vermont and Dartmouth Hitchcock and your expansion of mental health treatment in rural areas of both states.

But help me understand a little bit what you said about institutional knowledge as being at least part of this problem, losing people and then new people coming on not quite knowing the protocol. Is that at least part of the reason why these protocols were not being followed to the letter?

I think that certainly plays into it. One of the other factors is that there are different areas that the OIG CAP visits hit every three years that they come, so it’s really making sure that we’re on our game every single day and that we’re accreditation-ready.

I will tell you that we have certainly put in place mechanisms to track these improvements as well as improvements from any survey. The day that the IG left, we got straight to work. Of the 24 items that they mentioned in there, and that there were findings for, six of them have already been closed out by the IG, eight more of those are in process and completed by White River Junction staff or very close to being turned over to the IG, and the remainder, the 10, are on track right now for completion.

Many of these are just collecting the documentation and making sure that there’s a record that shows a sustained improvement.

You may have sold yourself a little bit short there, Al, because I believe seven of them were closed out according to the OIG, not six. Seventeen still in the works. What’s it going to take to clear this up? Do you need more staff, more training for staff?

Actually, we’re already doing what we need to do. It’s a lot of staff getting engaged and making sure that we follow these through to completion. Some of these are making sure that we even have modified notes in our electronic medical record to show that documentation.

This is a reminder to us here in White River Junction that we need to be on point every single day and make sure that the documentation we put into the system is on point and as accurate as possible.

Data collection of course was a key point here. By some metrics, the hospital does quite well—wait times are low on average and the report  indicates that in some ways access to care has improved.

But the OIG also criticized the way the hospital collects data. So how can we trust that the stats cited by the hospital that show things are good are trustworthy?

Since I’ve been a permanent director here, since June 12th of last year, we have put in place mechanisms that were not in place before. Right now we have a quality management department that, when I came, only had two individuals. We’re now upwards of four or five individuals. We’re actually about to make a selection for a quality management officer to lead that group, which is something that we haven’t had in at least nine of the twelve months I’ve been here.

I will tell you that part of my background and my skill set is in looking at data and making sure that we use the data appropriately to manage care and manage operations throughout the facility. I will tell you that based on that and my experience, I actually had the report card created where we can track this and track every survey’s results to make sure that we’re hitting it on point.

Do you believe that patients are now safe in the hands of caregivers at White River?

Peter, as you know, I’m a veteran myself—10 and a half years in the Air Force, I was medically separated—I get a hundred percent of my healthcare at the VA and here in White River Junction, and I can tell you unequivocally that our veterans who come in here do get safe, quality care.

I think one thing to note is that, as in any healthcare organization  across the country, there are going to be mistakes made, and the thing that is important to me is how do you improve from those mistakes and how do you learn?

As you know, I have an open-door policy as well, where veterans are welcome to come in at any time…We certainly welcome feedback from veterans, family, and stakeholders. We do have a town hall, a public town hall, that is occurring next week on the 30th, and it will be starting here at 12:00pm over in building 44, room 103. It will go from 12:00 to 1:00, as well as tours afterwards.

So we’re really trying to make sure that we’re being transparent and that we’re listening to the voices of our veterans and the way they want their healthcare delivered.