Department of Veterans Affairs

Office of the Medical Inspector Site Visit Report Action Plan

1

Facility: 442 Report Date: 3/26/14 VISN: 19 Point of
Contact: Cynthia McCormack, MCD
Issue/ Recommendation Plan of Action Responsible
Person(s)
Target
Date(s)
Status of Actions OMI
Comments
1.a. Ensuring that all clinical
providers follow-up on patient
cancellations as stated in the
directive.
Ambulatory Care sent the
national and local policies
to all staff in the
department and the
policies were discussed at
staff meetings. All provider
cancellations are reviewed
by another LIP for clinical
need and the patient is
contacted for any
immediate needs.
Physician
Director,
Ambulatory
Care
1/17/2014 Complete, Documentation of
receipt of the policy has been
recorded. This is mandatory
training for all new staff.
100% of all provider clinic
cancellations are reviewed by
another provider. Documentation
of all reviews is available.


1.b. Aligning the VistA
scheduling systems scheduling
parameters so that they will be
congruent with VHA policy
Business Office ensured
that all clinics meet the
national Directive 2010-27
and facility policy 111-11-
01 with clinic availability
open a minimum of 90
days into the future.
Chief,
Business
Office
1/15/14 Complete


1.c. Conducting a review of the
directive for all current and newly
assigned providers and MSAs,
and provide a copy of the
directive.
Ambulatory Care sent the
national and local policies
to all staff in the
department and and the
policies were discussed at
staff meetings. MSAs
were provided a copy of
directive 2010-27 at the
refresher training. Upon
hire, new staff will be given
a copy of the directive.
Physician
Director,
Ambulatory Care
1/17/2014 Complete. Follow up of newly
assigned staff is conducted within
2 weeks of hire. Documentation
of receipt of the policy and
training has been recorded.


1.d & e. Closely monitoring the
patients recaptured off of the
Recall/Reminder discrepancy list
for quality issues and address as
appropriate.
Ambulatory Care sent a
copy of the Business office
SOP to all Ambulatory
Care Staff.
Business Office developed
Physician
Director,
Primary Care
2/20/2014 Complete. Documentation of
receipt of the policy has been
recorded.



Department of Veterans Affairs
Office of the Medical Inspector Site Visit Report Action Plan

2

Developing a process to ensure
that MSAs monitor and manage
the patients on the
Recall/Reminder discrepancy list
on a regular basis.
a Standard Operating
Procedure (SOP) for the
Recall/Reminder
discrepancy list. MSAs
run the list for their
assigned clinics one time
per week. They check to
see if the patient has been
seen or has a scheduled
appointment. If the patient
has an appointment the
recall reminder is
removed. If the patient
has not been scheduled
the MSA contacts the
patient and schedules an
appointment. Delinquency
lists are reviewed weekly
by the Lead MSA to verify
that work has been
accomplished.
A review of the current
delinquency list for all
Primary Care clinics was
completed on 3/20/14;
there are 687 patients on
the list, a decrease of 76%
since November 2013.
1.f. Discontinue the practice of
blind scheduling of patients.
Business Office conducted
MSA refresher training on
1/13/14 and 1/28/14 during
which blind scheduling
was addressed in detail.
Monitoring is completed to
ensure compliance with
this item.
Chief,
Business
Office
1/31/14 A Business Office staff member
calls two patients per MSA per
week to verify that personal
contact with the MSA occurred
when their appointments were
scheduled. Additionally, the
Veterans are asked if the MSA
asked them when they would like
to be seen.

2. Ensure that all staff with
access to the scheduling
package receives re-training on
Refresher training was
completed. Monthly audits
Chief,
Business
Office
1/31/14
Audits are
completed
Complete. Documentation of
training has been recorded.
Audits are completed monthly.


Department of Veterans Affairs
Office of the Medical Inspector Site Visit Report Action Plan

3

the proper use of the Create
Date and Desired Date and
monitor compliance.
are completed on every
staff person that has
scheduling access to
ensure compliance with
Desired Date.
monthly
3.Ensure that Soft Skills training
is completed by all appropriate
staff within the required time
frame.
Business Office conducted
Soft Skills training on
December 19 and 20,
2013. All staff with access
to scheduling are
compliant . In the future,
new MSAs (or other staff
with scheduling access)
will receive Soft Skills
training within 1 year.
Physician
Director,
Ambulatory Care
1/15/14 Complete. Documentation of
training has been recorded


4. Staff the Clinic to be in
compliance with PACT staffing
model.

Ambulatory Care has
presented an overview to
the PACT staffing model at
the monthly staff meetings
in January along with face
to face meetings with
individual providers.
Physician
Director,
Ambulatory
Care
Nurse
Manager,
Ambulatory
Care
2/20/2014 The PACT staffing ratio goal is
3:1. FTC is currently at 2.62 and
Greeley is 5.0 (Jan FY14).
Greeley has 2 provider vacancies;
when filled will ratio. FTC is
hiring 0.5 MSA for a total of 3.5
FTEE; no other staff shortages.
PCMM coordinator participated
with national audit 3/4/14 to
ensure correct mapping of all
PACT teamlets. FTC shows a
continuous upward trend toward
goal. Efforts will continue to
acquire and maintain the PACT
staffing ratio goal.

5. Review Advanced Clinic
Access principles and strategies
in accordance with the PACT
model.
The ACOS/AC and COS
provide education to
providers and staff
regarding the PACT model
Physician
Director,
Ambulatory Care
Chief of Staff,
Cheyenne VAMC
& Clinics
Nurse
Manager,
Ambulatory
Care
11/2013 to
present:
weekly to
monthly
staff
meetings
Completed. The minutes reflect
weekly to monthly meetings held
with providers, nurses and MSAs
discussing the PACT model
including: What a PACT Team is,
The principles of PACT, what a
huddle is, and how to scrub
panels.



Department of Veterans Affairs
Office of the Medical Inspector Site Visit Report Action Plan

4


6. Develop a contingency plan
for short-term and long-term
provider absences.
Ambulatory Care
developed a policy to
address short and long
term provider absences.
Physician
Director,
Ambulatory
Care
2/28/2014 1. Implement the short term
cancellation policy
2. Identify coverage provider daily
to see patients
3. Implement a telehealth option
for more flexibility
4. Utilize a back-up licensed
independent practitioner for long
term absences.


7. Consider extending Clinic
hours to appropriately facilitate
access and recapture all of the
patient on the Recall/Reminder
discrepancy list.
Ambulatory Care
developed extended tours
to provide extended hours.
Physician
Director,
Ambulatory
Care
1/31/2014 Saturday clinics are held 8 am to
noon on non-holiday Saturdays.
Ambulatory Care providers
provide extended patient hours.