Department of Veterans Affairs

Office of the Medical Inspector – Site Visit Report Action Plan

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Facility: 442 Report Date: 3/26/14 VISN: 19 Point of Contact: Cynthia McCormack, MCD

Issue/ Recommendation Plan of Action Responsible Person(s)

Target Date(s)

Status of Actions OMI Comments

1.a. Ensuring that all clinical providers follow-up on patient cancellations as stated in the directive.

Ambulatory Care sent the national and local policies to all staff in the department and the policies were discussed at staff meetings. All provider cancellations are reviewed by another LIP for clinical need and the patient is contacted for any immediate needs.

Physician Director, Ambulatory Care

1/17/2014 Complete, Documentation of receipt of the policy has been recorded. This is mandatory training for all new staff. 100% of all provider clinic cancellations are reviewed by another provider. Documentation of all reviews is available.

1.b. Aligning the VistA scheduling system’s scheduling parameters so that they will be congruent with VHA policy

Business Office ensured that all clinics meet the national Directive 2010-27 and facility policy 111-11-01 with clinic availability open a minimum of 90 days into the future.

Chief, Business Office

1/15/14 Complete

1.c. Conducting a review of the directive for all current and newly assigned providers and MSAs, and provide a copy of the directive.

Ambulatory Care sent the national and local policies to all staff in the department and and the policies were discussed at staff meetings. MSA’s were provided a copy of directive 2010-27 at the refresher training. Upon hire, new staff will be given a copy of the directive.

Physician Director,

Ambulatory Care

1/17/2014 Complete. Follow up of newly assigned staff is conducted within 2 weeks of hire. Documentation of receipt of the policy and training has been recorded.

1.d & e. Closely monitoring the patients recaptured off of the Recall/Reminder discrepancy list for quality issues and address as appropriate.

Ambulatory Care sent a copy of the Business office SOP to all Ambulatory Care Staff.

Business Office developed

Physician Director, Primary Care

2/20/2014 Complete. Documentation of receipt of the policy has been recorded.

Department of Veterans Affairs

Office of the Medical Inspector – Site Visit Report Action Plan

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Developing a process to ensure that MSA’s monitor and manage the patients on the Recall/Reminder discrepancy list on a regular basis.

a Standard Operating Procedure (SOP) for the Recall/Reminder discrepancy list. MSA’s run the list for their assigned clinics one time per week. They check to see if the patient has been seen or has a scheduled appointment. If the patient has an appointment the recall reminder is removed. If the patient has not been scheduled the MSA contacts the patient and schedules an appointment. Delinquency lists are reviewed weekly by the Lead MSA to verify that work has been accomplished.

A review of the current delinquency list for all Primary Care clinics was completed on 3/20/14; there are 687 patients on the list, a decrease of 76% since November 2013.

1.f. Discontinue the practice of blind scheduling of patients.

Business Office conducted MSA refresher training on 1/13/14 and 1/28/14 during which blind scheduling was addressed in detail. Monitoring is completed to ensure compliance with this item.

Chief, Business Office

1/31/14 A Business Office staff member calls two patients per MSA per week to verify that personal contact with the MSA occurred when their appointments were scheduled. Additionally, the Veterans are asked if the MSA asked them when they would like to be seen.

2. Ensure that all staff with access to the scheduling package receives re-training on

Refresher training was completed. Monthly audits

Chief, Business Office

1/31/14 Audits are completed

Complete. Documentation of training has been recorded. Audits are completed monthly.

Department of Veterans Affairs

Office of the Medical Inspector – Site Visit Report Action Plan

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the proper use of the Create Date and Desired Date and monitor compliance.

are completed on every staff person that has scheduling access to ensure compliance with Desired Date.

monthly

3.Ensure that Soft Skills training is completed by all appropriate staff within the required time frame.

Business Office conducted Soft Skills training on December 19 and 20, 2013. All staff with access to scheduling are compliant . In the future, new MSA’s (or other staff with scheduling access) will receive Soft Skills training within 1 year.

Physician Director,

Ambulatory Care

1/15/14 Complete. Documentation of training has been recorded

4. Staff the Clinic to be in compliance with PACT staffing model.

Ambulatory Care has presented an overview to the PACT staffing model at the monthly staff meetings in January along with face to face meetings with individual providers.

Physician Director, Ambulatory Care Nurse Manager, Ambulatory Care

2/20/2014 The PACT staffing ratio goal is 3:1. FTC is currently at 2.62 and Greeley is 5.0 (Jan FY14). Greeley has 2 provider vacancies; when filled will ratio. FTC is hiring 0.5 MSA for a total of 3.5 FTEE; no other staff shortages. PCMM coordinator participated with national audit 3/4/14 to ensure correct mapping of all PACT teamlets. FTC shows a continuous upward trend toward goal. Efforts will continue to acquire and maintain the PACT staffing ratio goal.

5. Review Advanced Clinic Access principles and strategies in accordance with the PACT model.

The ACOS/AC and COS provide education to providers and staff regarding the PACT model

Physician Director,

Ambulatory Care Chief of Staff,

Cheyenne VAMC & Clinics Nurse Manager, Ambulatory Care

11/2013 to present: weekly to monthly staff meetings

Completed. The minutes reflect weekly to monthly meetings held with providers, nurses and MSAs discussing the PACT model including: What a PACT Team is, The principles of PACT, what a huddle is, and how to scrub panels.

Department of Veterans Affairs

Office of the Medical Inspector – Site Visit Report Action Plan

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6. Develop a contingency plan for short-term and long-term provider absences.

Ambulatory Care developed a policy to address short and long term provider absences.

Physician Director, Ambulatory Care

2/28/2014 1. Implement the short term cancellation policy 2. Identify coverage provider daily to see patients 3. Implement a telehealth option for more flexibility 4. Utilize a back-up licensed independent practitioner for long term absences.

7. Consider extending Clinic hours to appropriately facilitate access and recapture all of the patient on the Recall/Reminder discrepancy list.

Ambulatory Care developed extended tours to provide extended hours.

Physician Director, Ambulatory Care

1/31/2014 Saturday clinics are held 8 am to noon on non-holiday Saturdays. Ambulatory Care providers provide extended patient hours.