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Salisbury VA gets 11 findings, gold seal in Joint Commission review

Late last year, the Salisbury VA received 11 findings and a gold seal of approval in a triennial report by its national accreditation agency.

The Joint Commission – a healthcare accreditation agency – reviewed the Salisbury VA in October 2014. Its audit included 11 findings, called recommendations for improvement and a Gold Seal of Approval for Hospital Accreditation. The audit was conducted in October unannounced. Results of the audit were released Thursday to the Salisbury Post.

“When you look at the amount of veterans and the amount of services we offer, it just validates the great quality of care that we are providing to the veterans,” said Salisbury VA Chief of Performance and Quality Jennifer Pritchard.

The Joint Commission’s review included all of the Salisbury VA’s facilities – the W.G. Hefner VA Medical Center, Charlotte, Winston-Salem and Hickory. Of the Joint Commission’s recommendations for improvement, most were in the Salisbury VA’s hospital facilities. Other recommendations were in Behavioral Health and Home Based Primary Care. Most of the recommendations or findings were at the W.G. Hefner VA Medical Center. One recommendation came from the Salisbury VA’s Winston-Salem facilities and another came from a facility in Hickory.

The three recommendations for care in the Salisbury VA’s hospital facilities included: a small rip in the arm of an exam table in Winston-Salem, a multi-dose vial being labeled with an incorrect expiration date in Hickory and a recommendation to improve auditory privacy in the emergency department.

When the audit was released to the Salisbury Post, all recommendations for improvement had been fixed or addressed, according to audit documents. The rip in the arm of an exam table was fixed before the Joint Commission’s survey wrapped up. Incorrectly labeled vials were disposed of and a visual cognitive aide was developed to calculate expiration dates. Audit documents said a long term construction project would expand the emergency department, resulting in improved auditory privacy. In the interim, white noise machines were installed and special noise blocking materials were ordered, according to audit documents.

Six recommendations were for engineering in the Salisbury VA’s hospital facilities. Three of the recommendations were to improve documentation, which included: revising tests documents for electro-mechanical door releasing devices, revising life-safety drawings for the operating room to mark storage of potentially combustible materials and including specific documents for the analysis of noise and vibration control on renovation projects in environment of care committee meeting minutes.

Joint Commission documents showed three engineering findings in the VA’s hospital facilities that were not related to revising documentation. A non-exit door did not have a “no-exit” sign during the audit. In the W.G. Hefner VA Medical Center’s building two, a 10-gallon trash container was sitting next to a recycling container, which a Joint Commission engineer said was too much potentially combustible material in one spot, according to audit documents. The final hospital facility finding stated that an emergency generator wasn’t fully tested in the same manner as guidelines state. All three findings were fixed before audit documents were released to the Salisbury Post.

The Joint Commission’s other two recommendations were in Home Based Primary Care, where over-the-counter vitamins were recommended to be included in patient medication lists, and Behavioral Health, where veterans living in Transitional Residence were recommended to label disposable food containers.

No recommendations for improvement were found in the Salisbury VA’s Community Living Center, according to audit documents.

In every area reviewed, the Salisbury VA received the Joint Commission’s Gold Seal of Approval, which the Joint Commission calls “an internationally recognized symbol of quality” on its website.

Audit documents didn’t include any findings or recommendations related to patient wait times.

Contact reporter Josh Bergeron at 704-797-4246

 

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