www.va.govReport Summary
Combined Assessment Program Review of the Wilmington VA Medical Center Wilmington, Delaware
Report Number 08-01428-11, 10/21/2008 | Full Report (PDF)
The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we provided fraud and integrity awareness training to 64 employees. The review covered six operational activities. The medical center complied with selected standards in the following three activities: (1) computerized patient record system business rules, (2) pharmacy operations, and (3) survey of healthcare experiences of patients. We made recommendations for improvement in the following three activities: QM – Complete all peer reviews within 120 days, ensure that providers are privileged to perform procedures that are within the capability of the setting and that all privilege actions are documented in the appropriate minutes, complete all required root cause analyses, and require that moderate sedation and reversal agent use are monitored and reported to the appropriate committee. Environment of Care (EOC) – Require that all EOC team members participate in all rounds and that all community based outpatient clinics are inspected semi-annually and reassess the number of employees needed to participate in annual fit-testing. Emergency Department (ED) Operations – Require that ED inter- and intra-facility medical record transfer documentation is complete.