The Roseburg Veterans Association campus received a 98.1 percent compliance rating in a recent hospital accreditation review conducted by the Joint Commission — with only 37 minor findings of 3,400 procedures evaluated.
“Thirty-seven sounds like a lot, said Interim Director Dave Whitmer. “I’m absolutely thrilled. That’s an A-plus where I went to school. The Joint Committee surveyors were very complimentary of the team, its knowledge and willingness to share and the positive attitude toward improvement.”
The unannounced survey, conducted every third year, evaluated the hospital, home care and behavioral health care services offered at the Brookings, Eugene, Roseburg and North Bend campuses.
Of the 37 findings, most were in the “low” category of “likelihood to harm a patient” and limited in scope, the report indicates. If numerous findings in a high-risk category had been discovered, the commission has the authority to close a facility, Whitmer said.
Whitmer said VA officials started last Monday to correct the issues and ensure they do not happen again.
“We will do this because this is what a High Reliability Organization (HRO) does on its journey to ensure zero harm and improve its operations to realize almost no errors,” he said.
It’s part of the VA’s goals to have leadership committed to safety and reliability, a culture of safety in which all employees contribute — and feel safe to do so — and empower employees to make changes and improvements.
“This has always been my goal as your interim director — to start us on this journey to being a High Reliability Organization and recruit new leaders who can sustain the changes we’ve made going forward,” Whitmer said.
Many of the findings were related to minor housekeeping issues, such testing fire extinguishers within the year, ensuring medical gas shut-off valves are not blocked by other equipment and improper storage of some medical supplies and personal clothing. Many infractions were corrected once they were pointed out, the report reads.
The only findings that received a slightly higher admonishment at the hospital facility included that instrument washers weren’t being tested daily, vital signs weren’t taken within 15 minutes after a patient received a blood transfusion, medical records in three of four patient records reviewed didn’t include a pain rating from the patient and that patient-rehydration records weren’t kept.
In the home care realm, the only findings of note included hand-washing protocol violations, missing “beyond-use” dates on certain medical supplies, and that one patient record didn’t indicate an evaluation had been conducted regarding fire risk for a patient on oxygen.
The behavioral health care survey conducted at the North Bend VA site had the lowest scores, and while considered “widespread,” they were still rated as having a low likelihood of harming a patient; many were corrected during the visit.
They included a nutritional screen didn’t include all the minimum required elements including weight gain and eating habits, treatment plans had not been updated, no standardized method was used to monitor a veteran’s progress toward their treatment goal, and all breathalyzer records were out of compliance with regards to recalibration.
“I’m so proud of our team and how well we did in this review,” Whitmer said. “They were not aware of the challenges we faced earlier in the year, and they were that much more impressed to know our team has rallied together for this kind of impressive survey result.”
Whitmer was brought to Roseburg to make improvements and hire a permanent director — he has, but can’t name that person yet, he said Tuesday at a Brookings VA quarterly meeting. Whitmer is returning to Florida Dec. 21.
“We’ve made great strides, but we can always do better,” he said. “We owe it to our veterans to commit to that as an organization: We will always strive toward improvement.”