Madison VA Hospital criticized, lauded in federal report

December 22, 2018

Madison’s Veterans Hospital needs to improve its handling of controlled substances, and patient wait times are longer than the national average, according to a new federal report.

But the hospital gets a top rating for quality improvement, and patient and employee survey results are similar to or better than average, says the report from the VA Office of the Inspector General.

The report, released Thursday, is based on an inspection in late August that was part of a routine process of assessing each VA hospital in the country every three years.

“The intent is for facility leaders to use these recommendations as a road map to help improve operations and clinical care,” the 68-page report says. “The recommendations address systems issues as well as other less-critical findings that, if left unattended, may eventually interfere with the delivery of quality health care.”

Another OIG report in August said the Madison VA provided deficient care for a mentally ill man who killed himself a day after being discharged last year.

The new report cites three shortcomings in management of controlled substances, saying the facility didn’t always follow proper procedures for destroying drugs or making sure drugs return to pharmacy stock. Some workers assigned to oversee controlled substances received the drugs, a conflict of interest.

Madison VA spokesman Paul Rickert said the deficiencies were “minor process issues, none of which negatively impacted patient care.”

The hospital also failed to make sure some licensed independent providers were evaluated by other providers with similar training and privileges.

Madison VA leaders concurred with recommendations to correct the problems and said they would implement them by May, according to the report.

Since July 2017, the average wait time for primary care appointments for new patients at the Madison VA has ranged from 9.5 days to 29.8 days, compared to about eight days nationally.

For established patients, the average wait times at the Madison VA have ranged from 5.7 days to 10.3 days, compared to about four days nationally.

The report doesn’t give any reasons for the longer wait times, which became a national concern a few years ago amid reports of veterans elsewhere dying while waiting for care.

Rickert said the hospital offers same-day access for veterans with urgent primary and mental health care needs. Its wait times compare favorably with those at many private hospitals, he said.

Since August 2015, the hospital has had three “sentinel events,” or incidents resulting in patient death, permanent harm, severe temporary harm or intervention required to sustain life.

The hospital has had seven “institutional disclosures,” or incidents in which patients or their representatives were told of adverse events that resulted in, or were expected to result in, death or serious injury. There was one large-scale disclosure, involving multiple patients.

No details were provided about the incidents, which happen around the country, or their rate compared to other hospitals.

The Madison VA received a 5-star, or top, rating for strategic analytics for improvement and learning, putting it roughly among the top 10 percent of VA hospitals nationally for quality improvement.

Nearly 80 percent of patients surveyed said they’d recommend the hospital to friends or family, compared to about 67 percent nationally.

Employees in Madison rated their leaders an average of 69 on a scale of 1 to 100, compared to 67.7 percent nationally.

The Madison VA saw nearly 43,000 patients last year and had nearly 480,000 outpatient visits, including at sites in Baraboo, Beaver Dam and Janesville, and in Freeport and Rockford, Illinois.

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