Accreditations

2007 was a banner year for CVAMC's performance during four external reviews.

• The VA System Wide On-going Assessment & Review Strategy (SOARS) team conducted a week long survey in March that covered all program areas. We received an excellent report with several significant strong practices noted during the visit; for example, SPD computerized crash cart inspections, automated call-back list for disasters, pre-employment screening (all nursing staff) to assure physical capability for positions, inventory management (GIP implemented in 10 areas), emergency management program with active community involvement, the implementation of cultural transformation in the NHCU areas, informative pocket/flashcards for infection control, medication reconciliation, and suicide prevention/assessment.

• During April 2007, our Laboratory Program received two outstanding reviews during our College of American Pathologists (CAP) and Food and Drug Administration (FDA) surveys. CAP reviewed our entire Laboratory Program and the FDA focused on our blood bank process.

• The last survey of the year was for our Work Restoration Program, which was conducted by the Commission on Accreditation of Rehabilitation Facilities (CARF). This was an excellent survey as there were zero recommendations. We demonstrated exemplary conformance to the following standards: Facility Safety Program and our complete and accurate medical record.

CVAMC has successfully completed all action items for areas for improvement from all surveys conducted in 2007. During 2008, we are looking forward to outstanding performances during the unannounced Joint Commission survey and our March 2008 review by the Office of the Inspector General (OIG).