Healthcare Inspection – Quality of Care Issues, West Palm Beach VA Medical Center, West Palm Beach, Florida 12/17/2014 07:00 PM EST

December 18th, 2014

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Healthcare Inspection – Quality of Care Issues, West Palm Beach VA Medical Center, West Palm Beach, Florida
12/17/2014 07:00 PM EST

OIG conducted an inspection in response to a letter forwarded by Florida Governor Rick Scott. The letter contained multiple allegations about the quality of care at the West Palm Beach VA Medical Center (facility), West Palm Beach, FL. We did not substantiate that events related to patient falls resulting in injury and the deaths of two patients were not reported or investigated. However, we found that the investigation of one of the seven patient falls that we reviewed was not timely. We did not substantiate the allegation that a patient missed a scheduled chemotherapy treatment; however, completion of the patient’s chemotherapy was delayed, and the incident was not reported to the Patient Safety Manager (PSM) as required. We did not substantiate the allegation that a patient was inappropriately given medication during a cardiac arrest or that the patient’s death was not properly reported or investigated; however, we found that the correct progress note was not used resulting in the Risk Manager not initiating the required review. We substantiated the allegation that a patient had the wrong lens implant placed in his eye during cataract surgery because the operative team failed to properly perform the time-out process. The PSM was not notified of the incident immediately, as required, using the Critical Incident Tracking Notification system. We did not substantiate the allegation that facility staff “covered up” or failed to disclose adverse events. We found that local policy for reporting patient incidents and/or safety concerns was not being followed, causing unnecessary delays and missed opportunities for early intervention. Although not an allegation, we found that Quality Management Service has been chronically understaffed. We made four recommendations.
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Review of Alleged Mismanagement at VHA’s Massachusetts Veterans Epidemiology Research and Information Center 12/16/2014 07:00 PM EST

December 17th, 2014

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Review of Alleged Mismanagement at VHA’s Massachusetts Veterans Epidemiology Research and Information Center
12/16/2014 07:00 PM EST

In August 2013, the Senate Committee on Veterans’ Affairs asked the Office of Inspector General to review allegations that the Massachusetts Veterans Epidemiology Research and Information Center’s (MAVERIC) security control weaknesses put veterans’ personal information and other sensitive information at risk. It was also alleged that the Boston Healthcare System (BHS) leased off-site commercial office space for MAVERIC staff the complainant considered wasteful. We substantiated the allegation that MAVERIC security control weaknesses put veterans’ personal information and other sensitive information at unnecessary risk. In December 2013, we found hard copy veterans’ personal information and unencrypted portable data storage devices unsecured in MAVERIC office space. The Veterans Health Administration’s (VHA), Office of Research Oversight (ORO), found similar issues in August 2013 when it conducted a review of BHS’ research groups. In light of the issues identified during our review and by ORO, we concluded that BHS had not taken sufficient action to safeguard the confidentiality of veteran personal information. This occurred because BHS did not establish sufficient oversight of MAVERIC physical security controls, such as ensuring secure storage of veterans’ personal information and encryption of portable storage media. We also substantiated the allegation that BHS leased off-site commercial office space, which we determined was under-utilized. VA BHS entered into a 5-year lease totaling about $938,000 without determining how much office space it needed and whether there was available VA space. As a result, we estimate VA BHS could spend about $593,000 over the 5-year lease period for under-utilized office space. We recommended the Director of Veterans Integrated Service Network 1, in conjunction with the Office of Information and Technology, improve oversight of MAVERIC physical security controls and implement a plan to maximize use of the off-site commercial space if continued need for the office space is justified. The Director of the Veterans Integrated Service Network 1 concurred with our recommendations and provided acceptable action plans.
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Man Pleads Guilty to Assault on a Federal Officer in VA Hospital Shooting Incident 11/16/2014 07:00 PM EST

December 17th, 2014

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Man Pleads Guilty to Assault on a Federal Officer in VA Hospital Shooting Incident
11/16/2014 07:00 PM EST

Penn. Man Faces Up to 1 Year in Prison for Assault Involving BB Gun at Wilmington, DE, VA Medical Center
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National Consult Delay Review and Associated Fact Sheet 12/14/2014 07:00 PM ESTsx

December 16th, 2014

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Healthcare Inspection – Evaluation of the Veterans Health Administration’s National Consult Delay Review and Associated Fact Sheet
12/14/2014 07:00 PM EST

OIG evaluated Veterans Health Administration’s (VHA’s) review of “unresolved” consults and the accuracy of VA’s summary, the National Consult Delay Review Fact Sheet (Fact Sheet), as requested by the Chairman of the House Veterans’ Affairs Committee (HVAC). Unresolved consults are requests for consultations that are open or active in patients’ electronic health records. In September 2012, VHA initiated a multi-phased review of consults that were unresolved for more than 90 days. By May 2014, the number of unresolved consults had decreased considerably. However, because VHA did not implement appropriate controls, we found it lacks reasonable assurance that facilities appropriately reviewed and resolved consults; closed consults only after ensuring veterans had received the requested services, when appropriate; and, where consult delays contributed to patient harm, notified patients as required by VHA policy. Our review of the Fact Sheet found several key statements related to the scope and results of VHA’s review of unresolved consults were misleading or incorrect. These statements were repeated by VHA leaders at meetings with congressional staff and during media events. In July 2014, VHA issued a letter to the Chairman of the HVAC that included information intended to clarify statements in the Fact Sheet. We recommended that the Interim Under Secretary for Health (1) conduct a systematic assessment of the processes each VA medical facility used to address unresolved consults during VHA’s system-wide consult review; (2) ensure that if a medical facility’s processes are found to have been inconsistent with VHA guidance on addressing unresolved consults, action is taken to confirm that patients have received appropriate care; and (3) after reviewing the circumstances of any inappropriate resolution of consults, confer with the Office of Human Resources and the Office of General Counsel or other relevant agency to determine the appropriate administrative action to take, if any.
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Healthcare Inspection – Follow-Up Evaluation of Quality of Care,

December 16th, 2014

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Healthcare Inspection – Follow-Up Evaluation of Quality of Care, Management Controls, and Administrative Operations, William Jennings Bryan Dorn, VA Medical Center, Columbia, SC
12/14/2014 07:00 PM EST

At the request of Members of the House and Senate Committees on Veterans’ Affairs, the OIG conducted an evaluation of conditions identified in the OIG report Quality of Care, Management Controls, and Administrative Operations, OIG Report No. 13-00872-71, issued February 6, 2014 (the initial report), at the William Jennings Bryan Dorn VA Medical Center (facility), Columbia, SC. The purpose of this follow-up review was to determine whether identified conditions have abated, continued unchanged, or worsened and whether OIG’s recommendations were implemented. In the initial report, we noted that critical leadership positions were filled by a series of “acting” and temporary managers over a period of several years which contributed to past delays in correcting identified deficiencies. A permanent Chief of Staff and Medical Center Director were installed in January and April 2014 respectively, which has accelerated the facility’s progress in addressing deficient conditions. However, many of the problems outlined in our initial hotline report still existed, in whole or in part, at the time of our follow-up visit (July 2014). We found that the facility had implemented corrective actions in response to the 12 recommendations in our initial report, yet improvements were still needed. We agree with closure of 2 recommendations and will continue to follow up on the remaining 10 recommendations from the initial report. In addition, during the July 2014 visit, we found improper storage of patient information, medical and surgical supplies, medications, grafts, and patches. We made one additional recommendation related to proper storage.
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VA to Pilot IBM Computer Technology to Assist Physicians in Caring for Patients

December 15th, 2014

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VA to Pilot IBM Computer Technology to Assist Physicians in Caring for Patients
12/15/2014 01:47 PM EST

VA to Pilot IBM Computer Technology to Assist Physicians in Caring for Patients

Two-Year Pilot Program Places Emphasis on Evidence-based Clinical Decisions

The Department of Veterans Affairs (VA) has begun a two-year pilot to study innovative approaches to quickly search electronic medical records and medical literature for relevant published studies. During the pilot, VA will assess how the technology may accelerate evidence-based clinical decisions.

“Physicians can save valuable time finding the right information needed to care for their patients with this sophisticated and advanced technology,” said Interim Under Secretary for Health Carolyn M. Clancy, M.D. “A tool that can help a clinician quickly collect, combine, and present information will allow them to spend more time listening and interacting with the Veteran. This directly supports the patient-centric medicine VA is committed to delivering every day.”

The IBM Corporation was selected to provide the system which uses its “Watson technology” made famous on Jeopardy! in 2011. Today, IBM is working with several healthcare organizations to apply Watson’s cognitive capabilities in helping doctors identify and analyze cancer treatment options. Learning about the opportunities and challenges these next-generation technologies may have is part of an ongoing effort for VA to advance the quality of healthcare provided to our Nation’s Veterans. During the pilot, clinical decisions will not be made on actual patient encounters, but instead will use realistic simulations. The notice can be found here:

https://www.fbo.gov/notices/1e9767c0e2880cf2e4ce98f75b113efa

For more information, visit http://www.va.gov/health/.

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Robert A. McDonald bio

December 11th, 2014

Robert A. McDonald was nominated by President Obama to serve as the eighth Secretary of Veterans Affairs and was confirmed by the United States Senate on July 29, 2014.
Prior to joining VA, Secretary McDonald was Chairman, President, and Chief Executive Officer of The Procter & Gamble Company (P&G). Under his leadership, P&G significantly recalibrated its product portfolio; expanded its marketing footprint, adding nearly one billion people to its global customer base; and grew the firm’s organic sales by an average of three percent per year. This growth was reflected in P&G’s stock price, which rose from $51.10 the day he became CEO to $81.64 on the day his last quarterly results were announced—a 60 percent increase from 2009 to 2013.
During his tenure, P&G was widely recognized for its leader development prowess. In 2012, Chief Executive Magazine named it the best company for developing leader talent. The Hay Group, a global management consulting firm, consistently cited P&G in its top-tier listing of the Best Companies for Leadership Study. The company received recognition for its environmental and social sustainability initiatives, including receipt of the Department of State’s Award for Corporate Excellence for P&G’s operations in Pakistan and Nigeria. In addition, using the company’s innovative water purification packets, P&G committed itself to the 2020 goal of “saving one life every hour” by annually providing two billion liters of clean drinking water to people in the world’s developing countries.
An Army veteran, Mr. McDonald served with the 82nd Airborne Division; completed Jungle, Arctic, and Desert Warfare training; and earned the Ranger tab, the Expert Infantryman Badge, and Senior Parachutist wings. Upon leaving military service, Captain McDonald was awarded the Meritorious Service Medal.
Secretary McDonald graduated from the United States Military Academy at West Point in the top 2 percent of the Class of 1975. He served as the Brigade Adjutant for the Corps of Cadets and was recognized by The Royal Society for the Encouragement of Arts, Manufacturing, and Commerce as the most distinguished graduate in academics, leadership, and physical education. He earned an MBA from the University of Utah in 1978.
The Secretary is personally committed to values-based leadership and to improving the lives of others. He and his wife, Diane, are the founders of the McDonald Cadet Leadership Conference at West Point—a biennial gathering that brings together the best and brightest young minds from the best universities around the world and pairs them with senior business, NGO, and government leaders in a multi-day, interactive learning experience.
The recipient of numerous leadership awards and honorary degrees, in 2014, Secretary McDonald was awarded the Public Service Star by the President of the Republic of Singapore for his work in helping to shape Singapore’s development as an international hub for connecting global companies with Asian firms and enterprises.

Robert A. McDonald was nominated by President Obama to serve as the eighth Secretary of Veterans Affairs

December 11th, 2014

Robert A. McDonald was nominated by President Obama to serve as the eighth Secretary of Veterans Affairs and was confirmed by the United States Senate on July 29, 2014.
Prior to joining VA, Secretary McDonald was Chairman, President, and Chief Executive Officer of The Procter & Gamble Company (P&G). Under his leadership, P&G significantly recalibrated its product portfolio; expanded its marketing footprint, adding nearly one billion people to its global customer base; and grew the firm’s organic sales by an average of three percent per year. This growth was reflected in P&G’s stock price, which rose from $51.10 the day he became CEO to $81.64 on the day his last quarterly results were announced—a 60 percent increase from 2009 to 2013.
During his tenure, P&G was widely recognized for its leader development prowess. In 2012, Chief Executive Magazine named it the best company for developing leader talent. The Hay Group, a global management consulting firm, consistently cited P&G in its top-tier listing of the Best Companies for Leadership Study. The company received recognition for its environmental and social sustainability initiatives, including receipt of the Department of State’s Award for Corporate Excellence for P&G’s operations in Pakistan and Nigeria. In addition, using the company’s innovative water purification packets, P&G committed itself to the 2020 goal of “saving one life every hour” by annually providing two billion liters of clean drinking water to people in the world’s developing countries.
An Army veteran, Mr. McDonald served with the 82nd Airborne Division; completed Jungle, Arctic, and Desert Warfare training; and earned the Ranger tab, the Expert Infantryman Badge, and Senior Parachutist wings. Upon leaving military service, Captain McDonald was awarded the Meritorious Service Medal.
Secretary McDonald graduated from the United States Military Academy at West Point in the top 2 percent of the Class of 1975. He served as the Brigade Adjutant for the Corps of Cadets and was recognized by The Royal Society for the Encouragement of Arts, Manufacturing, and Commerce as the most distinguished graduate in academics, leadership, and physical education. He earned an MBA from the University of Utah in 1978.
The Secretary is personally committed to values-based leadership and to improving the lives of others. He and his wife, Diane, are the founders of the McDonald Cadet Leadership Conference at West Point—a biennial gathering that brings together the best and brightest young minds from the best universities around the world and pairs them with senior business, NGO, and government leaders in a multi-day, interactive learning experience.
The recipient of numerous leadership awards and honorary degrees, in 2014, Secretary McDonald was awarded the Public Service Star by the President of the Republic of Singapore for his work in helping to shape Singapore’s development as an international hub for connecting global companies with Asian firms and enterprises.

VA Implements National Hypoglycemic Safety Initiative

December 11th, 2014

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VA Implements National Hypoglycemic Safety Initiative
12/10/2014 02:35 PM EST

VA Implements National Hypoglycemic Safety Initiative

Empowering Veterans to Personalize their Diabetes Care

As part of the Department of Veterans Affairs’ (VA) ongoing effort to improve Veterans’ access to healthcare, VA is announcing the launch of a national Hypoglycemic Safety Initiative (HSI) to encourage diabetic Veterans receiving VA care to seek support to lower the risk of hypoglycemia (low blood sugar). The new initiative will enable Veterans living with diabetes to work more closely with their VA clinicians to personalize health care goals and improve self-management of the disease.

“The Hypoglycemic Safety Initiative is designed to enable Veterans and their families, partners and caregivers to create a personal plan for blood sugar management based upon the Veteran’s unique health goals,” said Dr. Carolyn Clancy, Interim Under Secretary for Health. “Our objective is to change how diabetes is managed in VA and the United States, and to help patients improve their personal well-being, not just manage their numbers.”

Diabetes is one of the most prevalent diseases among older Americans, with one in four Veterans suffering from the disease. Recent clinical studies indicate that when diet, exercise and stress reduction are not successful, the benefits of achieving intensive blood sugar control with medication are less effective. This is especially true for hypoglycemic agents (pills or insulin) used for those patients who have had diabetes for many years and those who have additional serious health conditions.

HSI’s key elements emphasize shared decision-making and universal health literacy to ensure Veterans understand the health information provided by their VA health care team. This includes the “teach back method” where Veterans and their caregivers are asked questions to be certain they understand and can act on key elements of self-management, including diet, exercise, glucose monitoring, managing medications, and insulin injections. The focus of the HSI is to help raise awareness among patients who may be at risk.

“Hypoglycemia has only recently been prioritized as a national public health issue, but Federal agencies are taking a leadership role in addressing the problem. We are proud to note the collaboration of VA with Department of Health and Human Services in aggressively addressing this problem,” Dr. Clancy added.

For more information about VA health care, please visit http://www.va.gov/health/.

###

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Riding for a Cause: Can-Am Spyder teams up with Road Warrior Foundation Dec, 05 2014

December 6th, 2014

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Riding for a Cause: Can-Am Spyder teams up with Road Warrior Foundation
Dec, 05 2014

As the Spyder team moves forward with the launch of the 2015 Can-Am Spyder F3, we want to take a moment to remind everybody of our exciting partnership with the Road Warrior Foundation (RWF). This is the second year of the partnership and we’re raising the bar even higher to help the organization accomplish its goals. We’re off to a great start, but we need your help!

The RWF mission is to provide adventure therapy to wounded, ill and injured U.S. Special Operations

Command Veterans; that is, memorable adventures that serve as one of the critical steps in their journey towards rehabilitation. BRP and Can-Am Spyder are playing a key role in bringing that mission to life through a series of rides, from which all donations will go directly toward funding ten wounded veteran riders for the RWF annual ride. This year, that ride will go from Valcourt, Quebec (BRP headquarters) to Key West, FL. Details are still being finalized, but it will take place in mid-2015.

The first RWF awareness ride was held Saturday, Nov. 8, with the help ofUS Spyder Ryders and Central Florida Powersports. By all accounts, it was a huge success! In addition to the RWF and special guest veteran riders who attended, nearly 30 Can-Am Spyder owners showed up to support and participate. The ride also generated more than $2,000 in donations!

One of the special guests is a retired Army Sergeant who used to ride motorcycles before he was severely injured in combat. He was so impressed with the Can-Am Spyder and loved the ride so much, he put down a deposit on a Spyder ST that day! Now that’s directly impacting the RWF mission.

This first ride was just the beginning of what we are hoping to be a series of great experiences with Spyder owners throughout the year. Please join us in helping this wonderful organization do what it does best – get U.S. Veterans out on the open road! Talk to your local dealer and Spyder riding community about coming together to host an RWF charity ride. Your dealer has the details on how to make it happen!

Tell us what YOU think!

- Facebook: facebook.com/CanAmSpyder,


- Twitter: twitter.com/officialspyder and

- Instagram instagram.com/officialspyder.

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