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Kansas City VA Medical Center

Specialty Care

The Kansas City Department of Veterans Affairs Medical Center is a 125 bed medical, surgical, and psychiatric facility. We value honesty and integrity as exhibited by open and effective communication and respectful and courteous interactions with all individuals. We strive for excellence by doing the right thing at the right time with the right resources for the right reasons.
We value fiscal responsibility with careful stewardship of allocated resources while maintaining state-of-the-art compassionate healthcare delivery and leadership which promotes and supports teamwork, diversity of ideas, accountability, responsibility, and employee development.

Primary Service Area

In addition to our tertiary care responsibilities, our primary service area comprises a 17 county- area in eastern Kansas and western Missouri. As a referral center for VA medical centers in Columbia, Missouri, Leavenworth, Topeka, and Wichita, Kansas, we provide health care for veterans throughout the Heartland. We also serve veterans in the northern part of Arkansas and from as far away as southern Iowa and southern Nebraska.

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Affiliations

The Kansas City VAMC has master agreements with the University of Kansas Medical School and University of Missouri-Kansas City Medical School. KCVA is functionally connected to KUMC. There are also affiliations with schools in nursing and allied health professions, including clinical pastoral education, psychology, social work, addiction counseling, gerontology, phlebotomy, pharmacy, dentistry, optometry, physician assistant, occupational and physical therapy, radiology technology respiratory therapy, dietetics, pathology, health care administration and medical records administration.

Research

The Kansas City Veterans Affairs Medical Center has an active Research and Development program. The philosophy of the Research Department is that both basic and clinical research can be used to continually advance medical science, and provide the latest, most advanced therapeutic environment for our veteran patients. Major areas of research being conducted at the Kansas City Veterans Affairs Medical Center include cancer treatment and prevention, gastrointestinal diseases, innovative approaches to bacterial infections, kidney disease, osteoporosis and other bone disorders, cardiovascular diseases, and substance abuse.

Population Served

The service area for KC VAMC includes the following counties:

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A. For In-Patient Care:

Missouri Counties:

Andrew Clinton Howell Pettis
Atchison Dade Jackson Platte
Barry Dallas Jasper Polk
Barton Daviess Johnson Ray
Bates Dekalb Laclede St. Clair
Benton Douglas Lafayette Saline
Buchanan Gentry Lawrence Stone
Caldwell Greene Livingston Taney
Carroll Grundy McDonald Texas
Cass Harrison Mercer Vernon
Cedar Henry Newton Webster
Christian Hickory Nodaway Worth
Clay Holt Ozark Wright

Kansas Counties:

Atchison Douglas Johnson Wyandotte
Brown Jackson Leavenworth
Doniphan Jefferson Nemaha

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B. For Out-Patient Care

Missouri Counties:

Bates Cedar Johnson Vernon
Caldwell Clay Lafayette St. Claire
Carroll Henry Ray
Cass Jackson Platte

Kansas Counties:

Linn Wyandotte Johnson

All health care providers, regardless of service line affiliation, collaborate to provide the treatment and care required to support patients in the promotion and maintenance of health; the prevention, detection, and treatment of disease or injury; and in providing support and appropriate care at the end of life. The plan for patient care delivery is designed to support continuous quality improvement and innovation in meeting the needs of the individual served and is developed based on the specific care needs (including unit specific) throughout the continuum.

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Scope of Services Provided

A. Primary Care

Primary Care services are provided through individualized care from a primary care provider at the parent facility and five Community Based Outpatient Clinics located in Belton, Missouri; Paola, Kansas; Nevada, Missouri; Cameron, Missouri and Warrensburg, Missouri. Primary Care services also include emergency care, same-day care (urgent care), women’s health care, eye care, dental care, and audiology services. The Primary Care Program supports and participates in the education of health care professionals.

B. Medical Subspecialty Care

Medical Subspecialty Care is provided through inpatient and outpatient primary, support and/or consulting services in the fields of Neurology, Cardiology, Hematology, Oncology, Gastroenterology, Pulmonary Medicine, Infectious Disease, Endocrinology, Nephrology, Dermatology, and Critical Care Medicine. The Medical Sub-specialty Care Program supports and participates in the education of health care professionals

C. Surgical Care

Surgical Care is provided through inpatient and outpatient primary, support and/or consulting services in the fields of Anesthesia, General Surgery, Ophthalmology, Orthopedic Surgery, Otolaryngology, Plastic Surgery, Podiatry, Urology, and Vascular Surgery. Neurosurgery and Oral Surgery are provided through Fee Basis. The Surgical Care Program supports and participates in the education of health care professionals.

D. Psychiatric Care

Mental Health Service provides inpatient and ambulatory primary, support and/or consulting care services in the fields of Psychiatry and Psychology. Other services provided include recreational therapy, substance abuse treatment, and the homeless program. The Mental Health Program supports and participates in the education of health care professionals.

E. Clinical Support

The Clinical Support Service provides support and/or consulting services in the field of Physical Medicine and Rehabilitation Services which include Physical Therapy, Occupational Therapy, EMG, Chiropractic Care, Pain Management, Telemedicine Clinics, and Speech Pathology. This service also provides support and/or consulting services in the following areas: SPD, Chaplain Services, Social Services, Dietary Services, Prosthetics and the services of transition nurses who act as liaisons between the hospital and community care services, e.g., nursing home, hospice, etc.

F. Radiology

Radiological services are available to inpatients and outpatients 24/7. This program also supports and participates in consultation and education of health care professionals

G. Pathology and Laboratory Service

Services are available to inpatients and outpatients 24/7. This program also supports and participates in consultation and education of health care professionals

H. Pharmacy

Pharmacy provides inpatient and ambulatory support and/or consulting services pertaining to medication use. Pharmacy services also include counseling of patients and continuing education for staff, and participation in research. Pharmaceutical care is available to inpatients and outpatients 24/7.

I. Health Systems Management (HSM)

Health Systems Management provides the clerical and administrative support to the providers and patients. This assistance is provided primarily through the OPT clinics and inpatient wards, along with specialized programs such as Compensation and Pension, Patient Beneficiary Travel, Admissions and Bed Control and Fee Basis services.

J. Information Management

The Information Management System provides patient, clinical, business and reference data to our providers and staff members. The system includes, but is not limited to, internal databases, external databases, electronic and paper patient medical records, and other reference and information sources available to our users.

K. Education

Education Service provides employee education and training, patient education, nursing education, medical library, graduate medical education, allied health training, continuing professional education, photography, illustration, audiovisual production and print reproduction. Services are provided primarily to medical center staff, and support for special events projects is provided to other medical centers in VISN 15 and the VISN 15 office and staff.

L. Facilities

The Facilities Management Service seeks to provide a comparable level of high quality services to all inpatients throughout the hospital as well as to those veterans served in the outpatient department. The staff of this Service are committed and actively involved in a process to continually strive to provide products and services in a manner that will exceed the expectations of our patients and other internal and external customers by:

• Maintaining a medical equipment management program designed to assess and control the clinical and physical risks of fixed and portable equipment used in the patient care area for the diagnosis, treatment, monitoring, and care of patients and of other fixed and portable electrically powered equipment

• Maintaining a utilities management program designed to assure the operational reliability, assess the special risks, and respond to failures of utility systems that support the patient care environment.

• Maintaining a life safety program designed to protect patients, personnel, visitors, and property from fire and the products of combustion and to provide for the safe use of buildings and grounds.

• Maintaining a bacteriologically clean environment.

• Assuring that clean linens are available and patient personal effects and valuables are available upon request.

• Maintaining a safety/sanitation program that is designed to provide a physical -environment free of hazards and to manage Facilities Program staff activities to reduce the risk of human injury.

M. Performance & Patient Care Improvement

The Performance and Patient Care Improvement (P&PCI) Service scope of service includes quality assurance, utilization management, risk management, patient safety, patient advocacy, infection control, credentialing and privileging, and compliance.

N. Research

Research is part of the VA mission. The goal is to continually improve the quality of the research performed at the Kansas City VA Medical Center and to ensure that compliance is maintained for all applicable regulatory requirements, including animal care and use, safety, and human subject compliance. For the 2005 fiscal year, 25 investigators were performing 128 active projects. An award winning VICTORS program provides state-of-the-art care for blindness and other visual disorders, while performing research to develop better treatments for these conditions. Other major areas of research being conducted at the Kansas City VA Medical Center include innovative approaches to gastric disorders, kidney disease, osteoporosis and other bone disorders, cardiovascular diseases and substance abuse. Total research funding for fiscal year 2005 was approximately $2.8 million.

O. Telemedicine

The Telemedicine Task Force of KCVA is responsible for coordination of telemedicine initiatives throughout the KC VAMC and the Community Based OPT Clinics (CBOCs). Currently, interactive-video mediated tele-education sessions are being done. The Home Telecare Coordination Project is scheduled to start in the middle of October 2004. This project is VISN-wide as well as a national project that extends care to the home for veterans with CHF, hypertension, diabetes mellitus, and COPD. Telepsychiatry will soon be available as well.

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Referrals

For services that can not be provided at this facility, patients are referred to outside facilities/agencies either routinely or for emergent service at/by, but not limited to, the following:

• Kansas University Medical Center
• Truman Medical Center
• Other VA Medical Centers and through their sharing agreements to DOD and private facilities (including dental laboratory Services by VA Central Dental Lab in Dallas, TX)
• Health Midwest Radiation Therapy Services
• Community Nursing Homes
• Community Home Health Agencies (including Mid America Regional Council on Aging, Division of Aging, Social Rehabilitation Services, Homeless Shelters)
• Adult Day Health Care
• St. Luke’s Health Care System for cardiac surgery, electro physiologic services

The following services are available through contracts/agreement with outside facilities:

• Agency nurses’ services
• Angioplasty
• Community Nursing Homes
• Community Home Health Agencies (including Mid America Regional Council on Aging, Division of Aging, Social Rehabilitation Services, Homeless Shelters)
• Vitrectomy & retinal detachment
• Lithotrypsy
• Gastroenterologist’s services
• Radiation therapy
• Sleep studies
• Ophthalmology
• Gynecology
• Home infusion therapy
• Dental technical work

For other diagnostic and rehabilitation services, patients are also referred to outside facilities/agencies for patient care either routinely or for emergent service at/by, but not limited to, the following:

KU Medical Center
Columbia VAMC
Leavenworth VAMC
Topeka VAMC
Wichita VAMC
St. Louis VAMC
Visiting Nurse Agencies
Community Nursing Homes
Home Care Equipment Company (Oxygen Contractor)
Doctors Equipment
Allan Medical (Springfield)
National Medical Care (Kansas City/Springfield)
Artificial Limb Contractors (Missouri/Kansas)
Orthotic (Brace Shops) Dealers (Missouri/Kansas)
Hill-Rom (DME Low air loss systems)
Athena Diagnostics, Worcester, MA
Baylor College of Medicine, Houston, TX
Children's Mercy Hospital, Kansas City, MO
Clinical Resource Center, Department of Veterans Affairs Medical Center, Minneapolis, MN

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Health Care Providers

Competency of providers is ensured through a detailed and rigorous credentialing and privileging process. Clinical Service Chiefs are responsible for recommending specific privileges for each staff member, for ensuring competency of each practitioner assigned to the program, for monitoring and reviewing practice patterns and for arranging for proctoring staff members for new privileges. The Medical Center Director, on the recommendation of the Chief of Staff and the Executive Committee of the Medical Staff (ECMS), issues all privileges.
Competency of practitioners, such as social workers, pharmacists, etc., who are not credentialed and privileged, is ensured through the following mechanisms/processes, as appropriate:

Definition of scope of practice
Competency checks
Regular review of proficiency
Continuing education

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Plan of Care Review

The plan for providing patient care is designed to reflect the medical center’s mission and support continuous quality improvement and innovation in meeting the needs of the individuals served. The appropriateness of this plan is reviewed as a part of the following functions:

Annual budget review process
Recruitment/retention
Staffing
Utilization Management
Quality Improvement
Peer Review
Consumer Affairs Contact
Strategic Planning Process

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HOSPITAL-WIDE SERVICES

SERVICES AVAILABLE TO INPATIENTS and OUTPATIENTS

AUDIOLOGY PRIMARY CARE

Scope of Care

Audiology provides comprehensive diagnostic, counseling, education/training, consultative or treatment services for veterans with hearing disorders. It has as its responsibility, the delivery of the highest quality patient care for hearing related disorders. This is accomplished through keeping current with the professional literature, training students from affiliated universities, and maintaining exemplary records so that administrative and clinical communication are maximized.

Staffing/Staffing Requirement

The clinic is staffed Monday through Friday, 8-4:30 PM, with a minimum of one (1) audiologist. Educational requirements for the Audiologist include the following:

• Doctorate Degree in Audiology
• Certificate of Clinical Competence in Audiology (CCC-A)
• Valid Missouri state license in Audiology
• In order to be credentialed, must have privileges in the following:
o Assessment of auditory evoked potentials & ENG
o Aural rehabilitation
o Student/trainee education/supervision
o Compensation and Pension Examinations
o Cerumen removal

The credentialing and certification process requires that clinic staff stay current regarding critical updates in a changing scientific profession. A minimum of 20 CEUs are obtained for each professional staff member over a two-year period. These education activities are obtained at national, state and local meetings, in addition to workshops. The curricula are highly weighted to both adult and geriatric training due to the high incidence of communicative disorders in this population.

The clinician is a member of the KCVA medical staff and has an appointment on the Kansas University Inter-campus program. This association provides the staff with the opportunity to supervise and consult involving clinical matters of communication across all ages and need.

The knowledge and skill levels of the staff member providing patient care is maintained through continuing education/training, bi-annual peer review of our medical staff members, and competency assessment of Audiology non-medical staff practitioners.

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CARDIOVASCULAR CARE SERVICES
Medical SubSpecialty Care

Scope of Care

The Cardiovascular Care area specializes in the delivery of diagnostic, invasive, and non-invasive cardiac procedures. These procedures include:

• Cardiac Catheterization
o Left and/or Right heart
o Coronary Angiograms (native and/or bypass grafts)
o Left Ventriculogram/Aortogram
o Cardiac outputs and valve calculations
o Shunt blood runs and shunt calculations
• Pulmonary Angiograms
• Permanent Pacemaker Implantation
• Temporary Pacemaker Insertions
• Rapid Atrial Pacing Overdrive
• Cardioverson
• Pericardiocentesis
• Stress Test
• Exercise Stress Test (Maximum or sub maximal)
• Exercise Stress Test with Thallium
• Pharmacological (Dipyridamole) Stress Test with Thallium
• Echocardiogram (to include: 2-D, M-Mode, Color Flow, and Doppler)
o Transthoracic
o Trans-esophegeal
o Bubble contrast
o Amyl nitrate studies
• Holter monitors
• Event recorders
• EKG

Requirements for Staff

Requirements for Registered Nurse:

• Current State Licensure as a Registered Nurse
• BCLS Certification
• ACLS certification
• Successful completion of the Critical Care Course
• Successful completion of Special Procedure Orientation
• Completed competency checks on:
o IV Therapy
o Airway Maintenance and Management
o Defibrillation
o Arrhythmia Detection
o System Assessment

Requirements for Technologists include:

• Current BLS Health Care Provider Certification
• Recognition of basic cardiac rhythm and arrhythmia
• Cardiovascular certification, Echocardiol0gy cert. or registration, and/or Radiology Registration preferred
• ACLS Certification preferred
• Knowledge of and the ability to perform various clinical duties:
o Sterile Technique
o Hemodynamic monitoring and recording
o 35 mm film processing technique
o Radiation safety practices

Staffing

Minimal staffing for the CV lab includes one (1) Cardiovascular Technologist and one (1) CV RN. (Prefer three CV personnel in cath. lab. for every cath; tow for pacemakers.) Personnel are available on Monday-Friday, except on holidays, from 0800-1630. Provisions for call back are available off-tour, weekends, and holidays.

Assignments/Responsibilities:

Registered Nurse

• Perform assessment and provide pre and post procedure nursing care
• Administer medications as ordered
• Monitor and provide patient education

CV Technologist

• Scheduling and preparing the patient for the procedure
• Coordinating OPT schedules between KCVA other and other VISN 15 hospitals
• Preparing the room and equipment for procedure
• Assisting in the performance of procedure
• Monitoring patients, as needed
• Post procedure care and patient education
• Filing encounters and record keeping
• Film developing, filing, tracking
• After care of equipment
• Maintaining proper inventory levels
• Patient education
• Patient transport

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CHAPLAIN SERVICE


Clinical Support


Mission of Chaplain Practice

In the development and maintenance of a program of spiritual health care in a pluralistic setting, the Chaplain Team recognizes the importance and value of spiritual health care in the overall care and treatment of patients, their support community of family, friends, and hospital staff. The mission of the team is to plan, develop, implement and evaluate a program of spiritual health care consistent with the greater mission of healthcare delivery in VHA and the KCVAMC. The KCVA Chaplain Team Mission is accomplished through the work of Clinical Chaplains, Contract/Fee Basis Chaplains, Clinical Pastoral Education Students, community clergy when appropriate, and volunteers supervised by chaplains

The Chaplain Team mission is accomplished through spiritual assessment and diagnosis, pastoral care and counseling, and worship opportunities for inpatients and outpatients. Patients range in age from young adults to the very old. Specific activities include, but are not limited to: spiritual assessments, individual and group spiritual and/or religious counseling, education in spirituality, bereavement counseling, public services of worship, including funerals and memorial services, and opportunities for ordinances, sacramental/ritualistic ministries and services for inpatients, outpatients, their relatives/friends, and staff. Pastoral care is also available to all staff in the medical center. Chaplains assist with patient education and counseling regarding advance directives, tissue and organ donation.

Scope of Care/Service

The Chaplain Team provides high quality care to inpatients and outpatients of this medical center. Patient care is provided on a continuing basis for eligible veterans and others with medical, surgical and psychiatric conditions in the context of which religious/spiritual issues are manifested.

The great majority of our patients are male and over 60 years of age. Patients are seen with the full range of acute, sub-acute, and chronic physical and mental illnesses. Many of our patients are not active religious practitioners; so many patients are in the hospital without clergy or other spiritual support person, which means they have no one in their lives to address their spiritual needs during the crisis of hospitalization. Their needs may represent spiritual injuries that include grief/loss, guilt/shame, alienation from a Higher Power, abandonment, anger/resentment issues and/or other concerns. Spiritual care is provided to the patient as well as his/her family support system; however, many of our patients have no family or they are estranged from them, which creates increased support needs across the admission/discharge planning spectrum.

Chaplains will be available for spiritual care needs throughout the medical center, with priority given to areas of highest clinical acuity. Routine visits are made to newly admitted patients and in outpatient clinics, to pre-op patients, and visits are made in response to staff referral, with priority given to patients in critical care and/or at end of life. Routine response is 48 hours, with immediate (within 30 minutes) response in emergent circumstances. Chaplains attend dying patients and provide supportive spiritual care to the patient’s family and friends as well. Chaplains facilitate spiritual education and counseling groups in the variety of mental health settings. Chaplain ministry will not be imposed upon those who decline it, and no efforts will be made by chaplains nor allowed by visiting clergy to proselytize patients to the clergyperson’s religious beliefs and practice

Chaplains work closely with clinical and administrative personnel throughout the medical center, especially interdisciplinary treatment teams and other direct patient care programs. A chaplain’s role and function may vary depending upon the program(s) or unit(s) where the chaplain practices. In any clinical setting, however, the primary goal of the Chaplain Team is to provide for the spiritual health of the patients and their families. The chaplain may be called upon to provide:

• pastoral ministry to individual patients experiencing spiritual injury or crisis, which will involve establishing a relationships with those patients;
• ministry to patients and their relatives/friends in crisis situations;
• opportunities for religious worship in an appropriate setting;
• pastoral care for patients in the interdisciplinary care team context; and
• education in spiritual and religious issues as part of the treatment plan.


Staffing

The Chaplain Team is an independently practicing, self-directed work team. The team consists of
Clinical Staff Chaplains (full-time, part-time, contract, and fee-basis), Chaplain Interns and Residents (number will vary from class to class), and a shared team secretary. One of the full-time chaplains also serves as Team Leader. Although organized under the Clinical Support Service, Chaplain Team serves patients and staff of all program lines in the medical center.

Support Services: Timely delivery of pastoral care for spiritual injury or crisis is paramount in addressing the human condition. Therefore, maintaining sufficient staff for the demands of the unique setting is critical to success in meeting the Chaplain Team mission. Along with the full-time staff, part-time, fee-basis and contract chaplains are essential to providing spiritual health care on a 24-hours-a-day, seven-days-a-week basis. Without the additional support staff, care of seriously ill and dying patients would be difficult.

Methods Used to Assess and Meet Patient’s Care Needs

Chaplain professionals practice through a variety of activities addressing the care goals of:

• accurately diagnosing the spiritual injury,
• utilizing the spiritual assessment for intervention, and
• developing and implementing a plan for the patient’s spiritual health care.

Chaplains also are responsible for educating patients in the meaning of their spiritual injury and methods of effective spiritual self-care. Methods for meeting these needs include direct inpatient care, follow-up and supplemental care in outpatient clinics, and consultation with other disciplines and teams in efforts of holistic patient care.

Definition of Terms:

The term pluralism/pluralistic refers to the environment in which members of diverse ethnic, social, racial, cultural, gender and religious groups live with equal rights and treatment as their individual identities and traditions are respected and honored. VA Chaplains give full affirmation and support to each other as well as to each individual patient without regard to differences.

The term ecumenism/ecumenical shall refer to the state in which general or universal truths and traditions are blended into a working unit or service.

The term patient refers to veterans and other persons eligible to receive healthcare treatment at this facility.

Clinical Pastoral Education Student will refer to those clergypersons and qualified laypersons participating in the Clinical Pastoral Education program of the health care system. Students in their first program of CPE are referred to as Chaplain Interns, and students in yearlong full-time programs of CPE are referred to as Chaplain Residents. The CPE Supervisor must be certified by the Association for Clinical Pastoral Education, Inc.

Contract Chaplains will refer to clergypersons utilized on a contractual or fee basis to provide spiritual health care in certain situations when a staff chaplain cannot meet the patient’s unique religious needs or when a staff chaplain is not available.

Clinical Staff Chaplains will refer to ordained clergypersons employed on either a full-time or part-time basis that have pre-scheduled regular tours of duty. These individuals have received clinical pastoral training, have prior pastoral experience, and are integrated into treatment teams in their areas of assignment in each medical center.

Visiting Clergypersons will refer to pastoral representatives from faith groups within the community. These clergypersons are welcome to visit patients who are members or participants in their religious communities.

Volunteer Clergypersons will refer to those clergypersons that assist the pastoral care staff with visitation of patients of their respective faith group. These persons will be supervised by a Clinical Staff Chaplain and be guided by the policies and procedures of the facility.

Chaplain Volunteers are laypersons working under the supervision of VAVS to assist with non-clinical tasks of the Chaplain Team.

Chaplain, without adjective, will refer to all classes of chaplains and students collectively, i.e., those identified in d, e and f above.

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CARDIOVASCULAR APN
Advanced Practice Nurse (APN)
Medical Subspecialty Care

Scope of Service

The Cardiovascular APN plans/provides primary, secondary, and tertiary health care/preventive care for the patient and family in the home, extended-care facility, clinic or inpatient setting. Physiological, psychological, sociological, developmental, cultural, educational and spiritual needs of the patient and family are considered in planning and initiating care.

The APN is in collaborative practice with the Cardiology Medicine Staff Physicians. Roles of the APN include clinical, consultant, educational, research, and administrative.

Requirements for Staff

• Current state license as registered nurse
• MSN required
• Completion of advanced physical assessment and advanced pharmacology, and EKG interpretation
• BLS required and ACLS provider preferred
• Minimum of two years experience dealing specifically with critical care patients and patients with cardiovascular problems
• Two years experience as advanced practice nurse preferred
• ANA Certification as advanced practice nurse preferred

Clinical Responsibilities

• Conducts history and physical examinations
• Initiates consults
• Has prescriptive privileges
• Writes Admitting orders
• Has disposition authority as appropriate
• Orders and reviews laboratory and other diagnostic testing/examinations
• Initiates change in treatment regimen as indicated during clinic/home/hospital visits
• Provides cardiovascular consultation to nursing staff and other health-care disciplines as requested
• Performs Permanent Pacemaker and Internal Defibrillator interrogation and programming
• Initiates long-term follow-up for patients with special cardiology needs i.e. permanent pacemaker, PCD, artificial heart valve
• Is resource for patient/family members to call for health-care needs to include sociological and psychological components
• Coordinates the out-patient cardiology special procedures/care: cardioversions, open heart program, pacemaker program, event monitoring, and others as appropriate
• Maintains communication between the other VISN Cardiology Staff regarding the KCVAMC Cardiology Patient(s)

Educational Component/Research

• Teaches/lectures as requested on Cardiology Practice/Issues
• Provides continuing education to staff members
• Precepts MSN graduate students
• Conducts nursing research
• Utilizes research findings in care of patients/families
• Involved in continuous quality improvement through analysis of indicator outcomes and initiating appropriate changes in the health-care delivery system

Administrative Responsibilities

• Serves on hospital-wide committees
• Develops/revises clinical protocols, hospital policies and procedures

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ENTEROSTOMAL THERAPY NURSE
Surgical Care


Scope of Care

An Enterostomal Therapy Nurse (ETN) provides acute and rehabilitative care for the patient with select disorders of the gastrointestinal, genitourinary and integumentary systems. The ETN provides direct patient care to persons with abdominal stomas, wounds, drains, pressure ulcers and incontinence. As an educator, consultant, researcher and administrator, an ETN plays a pivotal role in the guidance of optimum patient care. The ETN is available during administrative hours during Monday-Friday, except on holidays.

Requirements for Staff

• Current state licensure
• BSN from an NLN accredited program
• Successful completion of an accredited ETN education program Certification
• Board certification is available through the Wound Ostomy and Continence Nurses Society to recognize expertise in the field of ETN and is preferred

Clinical Responsibilities

• Uses the nursing process to provide quality care for a specific group of patients
• Acts as a consultant in clinical practice and shares clinical expertise with other medical personnel
• Collaborates with other health care personnel to provide continuous, comprehensive patient care
• Participates in the development, implementation and interpretation of practice standards & service policies, peer review, quality management programs and other activities that impact the delivery of care and cost containment
• Maintains communications with manufacturing representatives to remain informed of current trends and provide a high quality of services to the patient population served by the ETN
• Uses current concepts and findings from research to design, implement, and evaluate initial and ongoing plans for patient care and initiate change in clinical practice when indicated

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PULMONARY ADVANCED PRACTICE NURSE

Medical Subspecialty Care


Scope of Service

The Pulmonary-Advanced Practice Nurse (Pulmunary APN) plans/provides primary, secondary, and tertiary preventive care for the patient and family in the home, extended-care facility, clinic or inpatient setting. Physiological, psychological, sociological, developmental, cultural, educational and spiritual needs of the patient and family are considered in planning and initiating care.

The Pulmonary CC CNS has prescriptive privileges in collaborative practice with pulmonary staff. Roles of the Pulmonary CC CNS include clinical, consultative, educational, research, and administrative.

Requirements for Staff

• Current state license as registered nurse
• MSN required
• Completion of advanced physical assessment and pharmacology
• BLS Health Care Provider
• ACLS provider preferred
• Minimum of two years experience with critically ill patients
• Two years experience as advanced practice nurse preferred
• Certification as advanced practice nurse required.

Clinical Responsibilities

These functions will be performed in collaboration with the attending staff physician who will monitor these activities. The following clinical responsibilities have been approved by the collaborating physician:

General:

• Conducts history and physical examinations
• Initiates consults
• Has prescriptive privileges: May prescribe medications in accordance with established pulmonary medical practice
• Has disposition authority
• Orders and reviews laboratory and other diagnostic testing/examinations
• Is a resource for patient/family members to call for health care needs which include sociological and psychological components
• Initiates change in treatment regimen as indicated during clinic/home/hospital visits
• Performs simple waived tests such as occult blood and urine dipsticks, and tests classified as Provider-Performed Microscopy. This does not include tests performed by an instrument or tests producing quantitative results.

Specific:

• Assists in performing bronchial-alveolar lavage
• Initiates ventilator- speaking valve for appropriate patients
• Lung cancer: Is responsible for maintaining follow-up on patients evaluated for lung cancer by pulmonary staff and arranging for subsequent treatment by interacting with thoracic surgery, oncology, or radiation therapy staff.
• Manages home ventilator patients
• Orders and modifies home oxygen prescriptions
• Administers conscious sedation

Educational Component/Research

• Provides continuing education to staff members
• Precepts MSN graduate students
• Conducts nursing research
• Utilizes research findings in care of patients/families
• Is involved in continuous quality improvement through analysis of indicator outcomes and initiating appropriate changes in the health-care delivery system

Administrative Responsibilities

• Initiates, manages, and evaluates pulmonary rehabilitation
• Serves on hospital-wide committees
• Develops/revises clinical protocols, hospital policies and procedures

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DENTAL SERVICES
Primary Care

Scope of Care

Complete dental care is provided to all veterans legally entitled to dental care as determined by the dental eligibility office.

Medical patients needing dental care will be provided such care as is essential to that patient’s medical condition. Dental treatment may be limited to treatment of trauma, control of pain and elimination of acute infection, depending on current staffing. Definitive treatment may be provided if consultation with patient’s primary care provider determines need for further dental treatment.

Staffing Plan

The Dental Clinic is staffed Monday through Friday, 8-4:30 PM, with a minimum of one (1) dentist. Services are available on call 24 hours a day.

Education Requirements

Dentist

• Graduation from an accredited US Dental School
• Current license

Hygienist

• Graduation from an accredited US Dental Hygiene Program
• Current license

Assistant

A minimum of one year experience as a dental assistant

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DIABETES CARE & EDUCATION
Medical Subspecialty Care

Scope of Care

This service will be carried out through an advisory body that will:
• Provide guidance and assistance to Program Directors in identifying problems, which need corrections.
• Identify new initiatives for improving care and containing costs.
• Communicate to the Chief of Staff and Medical Director.
• Consider any clinical, administrative, or educational topic serving to promote the quality of care rendered to patients with a primary or secondary diagnosis of diabetes mellitus.
• Oversee formal diabetes patient education programs.

Diabetes Advisory Committee

The advisory body will consist of representatives of services and sections that are commonly involved with the treatment of diabetes mellitus and its complications: Endocrinology, Primary Care, Ophthalmology, Podiatry, Dentistry, Nursing, Dietetics, and Pharmacy.

Delivery System

Formal diabetes education will be performed in group classes and on an individual basis by a Certified Diabetes Educator (CDE). A variety of formal programs are held every Monday through Friday. Other nurses may do reinforcement of formal education programs. Documentation of the education is in the progress notes of the medical record.

Individual instructions may be done through consultation to the Diabetes Educators. Patients may be referred for diabetes education by any caregiver (e.g., physicians, physician assistants, nurse practitioners, nurses).

Registered Dietitians/CDEs will perform patient instruction and counseling on meal planning guidelines as well as individualized meal plans.

Requirements for Educators

• Nurse – RN, with CDE certification or CDE eligible
• Registered Dietitian who is a CDE or CDE eligible
• Registered Pharmacist or Pharm D

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DIALYSIS - 6E
Medical Subspecialty Care


Scope of Service

This is an outpatient and inpatient dialysis unit, which specializes in the delivery of comprehensive care for patients requiring acute and chronic dialysis and pre- and post kidney transplantation. The scope of care provided by nursing personnel in the dialysis area includes providing:

• Pre-dialysis education
• Center hemodialysis
• Acute hemodialysis
• Home training (peritoneal dialysis)
• Home patient monitoring
• Transplant workup and follow-up
• Home patient back-up dialysis care (all home hemodialysis and peritoneal patients.)

Requirements for Staff

Requirements for the RN staff include:

• Three (3) years successful nursing practice (ICU and/or dialysis experience preferred)
• Current state licensure
• Current BCLS certification
• Successful completion of dialysis orientation plan
• Successful completion of mandatory in-services
• Successful completion of unit based competency exam
• Successful completion of peritoneal dialysis competency

Requirements for the Dialysis Technician include:

• Ability to operate life saving medical equipment
• Ability to monitor vital signs, assess patient’s condition, recognize emergency & potentially critical situations
• Ability to perform routine cleaning procedures requiring standard precautions

Patient Care Delivery System

The dialysis unit utilizes a team approach, with primary patient care assignments, to incorporate the standards of care for the ESRD patient. Care within this unit focuses on the patient being involved with his own care. The family or significant other is also involved in the care, support and education when necessary.
The charge nurse will do assignment of patient care on a daily basis. Although all staff can provide all aspects of care, the assignments are based on patients' acuity level or needs as an inpatient (i.e., acute dialysis in ICU or PD patients on ward). The charge nurse typically is involved with coordinating all aspects of care in and outside the dialysis unit and also receives and troubleshoots phone calls from home patients in the absence of the home training coordinator. The RN responsible for making these assignments will be familiar with these policies and procedures and will review them as necessary to keep his/her information current.

Staffing

A combination of primary nursing and individual daily assignments are used to deliver care within this unit. A Nurse Manager is assigned to the unit and all personnel report directly to this individual, except the social worker and dietitian. A Charge Nurse is assigned during the hours the hemodialysis unit is open as follows:

7:00 a.m.-5:30 p.m.: Monday, Wednesday, and Friday
7:00 a.m.-5:30 p.m.: Tuesday, Thursday, and Saturday

All members of the nursing staff are trained to deliver all aspects of care for the dialysis patient. RN Staff is assigned on call duties to cover acute and chronic dialysis and home patient needs when the unit is closed on Sunday. Minimum staffing is as follows:

Monday/Wednesday/Friday: 3 RNs or 2 RNs 1 /LPN and 2-3 Dialysis Technicians
Tuesday/Thursday/Saturday: 2 RNs or 1 RN/ 1 LPN and (1) Dialysis Technician (a mix of RN/LPN on any given day equals 3-4 licensed staff daily)

The Transplant Coordinator works five days per week and performs on-call and works some Saturdays per Nurse Manager.

The Home Training Coordinator works five days per week; performs on-call and works some Saturdays per Nurse Manager.

The technical staff is trained to deliver all aspects of technical support for the dialysis patient.

The Administrative Assistant is available Monday through Friday and is assigned directly to the Dialysis unit. The Administrative Assistant provides administrative/clerical support to the unit.

The Social Worker (0.5) for the dialysis unit is available Monday through Friday but a Social Worker is on-call on Saturday and Sunday. The Social Worker is trained to provide psycho/social assistance for the dialysis patient; however, the Social Worker is also assigned other patient care duties within the Medical Center.

The Dietician 0.5) assigned to the dialysis unit is available Monday through Friday but a Dietitian is on-call on Saturdays. The Dietitian is trained to provide nutritional support to the dialysis patient; however, the Dietitian is also assigned other patient care duties within the Medical Center.
Staffing Plan

Days (M-W-F) Days (T-Th) Sat Only 7AM (Sun) Thru
-7AM (Mon)

3 RNs or 2 RN’s /1 LPN 2 RNs or 1 RN /1 LPN 3 RN 1 RN On Call daily when center is closed. 2-3 Technicians 1 Tech 1 Tech On-Call hrs 1730-12MN and MN - 0630

Physician Providers: There is a 24-hour physician coverage provided (Nephrologist, Fellow, Resident). Vascular surgeons are available to provide hemodialysis and peritoneal dialysis access as required.

Support Staff: Days (Monday – Friday)

Nurse Manager 0.40
Administrative Assistant 1.00
Social Worker 0.50
Dietician 0.50

Respiratory Therapy: Provides coverage for scheduled respiratory treatments and for emergent/life threatening situations.

Pharmacy

Pharmacy services are available 24 hours a day. Ward stock is delivered as needed. A clinical pharmacist is available for consultation and to provide educational services to patients/staff via phone or pager.

Other Support Services/Functions:

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MEDICAL SUBSPECIALTY CARE
CONSULTING SERVICES


Scope of Services

Medical Care is provided by multiple disciplines that provide consulting services in the following fields of specialty:

• Cardiovascular
• Dermatology
• Endocrine
• Gastroenterology
• Pulmonary Medicine
• Oncology
• Nephrology
• Infectious Disease
• Neurology

Credentialing & Privileging

• Credentialing and privileging of independent practitioners
• Monitoring and review of practice patterns, including proctoring of new medical staff members
• Definition of scope of practice
• Competency checks
• Regular review of proficiency
• Continuing education

The Service Chief is responsible for recommending specific privileges for each medical staff member, for ensuring competency of each practitioner assigned to the program, for monitoring and reviewing practice patterns, and for arranging proctoring of new staff members. All privileges are issued by the Medical Center Director, on the recommendation of the Chief of Staff and the Executive Committee of the Medical Staff.

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CLINICAL NUTRITION
Nutrition & Food Services
Clinical Support Service


SCOPE OF CARE

The clinical nutrition staff seeks to provide high quality nutrition care and service to inpatients throughout the hospital as well as to those veterans served in the outpatient departments. As stated in the VHA Goals, the staff is committed to provide products and services in a manner that will exceed the expectations of our patients and other internal and external customers.

The clinical nutrition staff provides nutrition care and education for both in-patients and outpatients treated at the Kansas City VAMC. The patient population is adult, both male and female, ranging in age from young adults to elderly. The five most common diagnoses served by the clinical nutrition staff are: Diabetes Mellitus, Cardiovascular Disease including Hypertension, Cancer, Chronic Obstructive Pulmonary Disease, and Psychiatric Illness including Substance Abuse.

The clinical nutrition staff is available to provide nutritional assessment and education for the medical, surgical, psychiatric, and intensive care unit patients. Nutritional care plans are developed, implemented, and evaluated for patients identified with nutritional problems or those identified as being at nutritional risk.

Nutrition services are also provided for outpatients by the clinical nutrition staff. The dietitian provides nutritional education for the patient and/or care provider in individual and/or group settings. The diabetes nutrition specialist teaches the nutrition part of the outpatient Diabetes Education program.

The clinical nutrition staff uses the following methods to assess and meet patient care needs: ward rounds, interdisciplinary discharge/patient care planning meetings, communication with the health care team, staff meeting presentations of data and discussions, peer reviews, and involvement in performance measurement and improvement.

Standards and guidelines for practice are available including VA manuals, Medical Center Professional Services Memorandums and policies and procedures, Diet Manual, Practice Guidelines for VA Nutrition and Food Service, American Dietetic Association Evidence based Nutrition Practice Guidelines, clinical nutrition textbooks, and current professional journals.

STAFFING PLAN/STAFFING AVAILABLE

The clinical nutrition staff consists of five registered dietitians. Each dietitian is assigned to designated patient care areas, wards, teams, programs and/or clinics. The clinical nutrition staff works full-time Monday through Friday and one dietitian is on-call each Saturday. The dietitian on-call on Saturday assures that nutrition assessment referrals are completed within the 48-hour time frame. If clinical nutrition services are needed at other times after scheduled working hours, a cascade phone list is implemented in order for a dietitian to be reached. Clinical nutrition staff is scheduled during the time periods when they are most frequently needed for consultation referrals and to be available to interact readily with other members of the health care team.

REQUIREMENTS FOR STAFF

The basic requirements for the clinical staff include, maintaining registration with the Commission on Dietetic Registration (CDR), the credentialing agency of the American Dietetic Association, ability to assess and educate patients, appropriately prioritize daily work, and participate as a member of the health care team. Clinical dietitians must also complete mandatory training annually for the VA Medical Center and must maintain registration with the CDR according to current established requirements.

RELATIONSHIP WITH OTHER SERVICES/SUPPORT SERVICES

The clinical nutrition staff provides nutrition consulting services to the following services: Surgical Care, Medical Subspecialty Care, Primary Care, Mental Health, and Clinical Support. In addition, clinical dietitians work in conjunction with other allied health services including Nursing, Pharmacy, Social Work, Dental, Chaplain, Pathology and Laboratory, Audiology and Speech Pathology, and Recreation to provide clinical services for inpatients and outpatients.

The clinical nutrition staff provides support to food service staff in interpreting diet orders and in planning specific diets, nourishments, and special foods to meet individual patient’s nutrition needs.

The clinical nutrition staff also receives support from the following services: Pharmacy, Business, Facilities, Information, Performance and Patient Care Improvement, Education, and Health Systems Management.

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MEAL SERVICES
Nutrition & Food Services
Clinical Support Service


Scope of Care

Nutrition and Food Service Nutrition and Food Service provides nutritious meals for all in-patients, lodgers, and for designated outpatients. Meals are planned and provided for both regular and modified diets according to the physician’s diet order for the patient. Modified diets are planned in accordance with standards in the Kansas City DVAMC Diet Manual. All diets are planned to be nutritionally adequate (i.e. meet the Dietary Reference Intakes for Essential Nutrition), if possible within the constraints of the diet order. Meals are planned to be appealing and to promote optimum intake according to the patient’s individual nutritional needs. Nutrition supplement products and between meal nourishments are provided to patients when needed for nutritional repletion, some disease states, or other individual nutritional needs. Nutrition and Food Service provides commercial enteral products for all in-patients receiving tube feedings. VA Manual M-2, Part III, Chapters 1-6 provides overall guidance for Nutrition and Food Service activities.

Nutrition and Food Service provides meal services from 6:00 a.m. to 8:00 p.m. seven days per week. If meal service is needed after 8:00 p.m. or before 6:00 a.m., special meal services are available by contacting the nursing supervisors. In addition to regular meal service, Nutrition and Food Service provides special meal services including:

• Late meal trays for patients needing meal service at times other than regular meal service hours
• Frozen “healthy” dinners stocked in a small freezer on 5W (nursing supervisors have access) for use by patients admitted or needing meal service after the kitchen is closed at 8:00 P.M.
• Sack meals for patients or lodgers on work pass or lengthy travel status
• Subsistence items such as crackers, canned soup, juices and coffee packets stocked on inpatient wards and designated outpatient areas
• “Nutrition packs” stocked in designated outpatient clinic areas for use by outpatients required to report fasting to the medical center for tests or treatment
• Hypoglycemia kits stocked on all in-patient wards and on designated outpatient areas for treatment of diabetic patients having hypoglycemic episodes

The clientele served is primarily adult and geriatric inpatients and outpatients and is predominantly male. Patients with all diagnoses are served including medical, surgical, and psychiatric patients. Special emphasis is put on meal planning and service for patients with diabetes, cardiovascular diseases, renal disease, and cancer because of the specialized nutrition needs of these patients.

Nutrition and Food Service staff work closely with the clinical to provide individualized meal services for patients having specific nutrition needs and to accommodate patient’s individual food preferences. Clinical dietitians assess the nutrition needs of patients requiring specialized nutrition care and communicate any changes needed in the patient’s meals or nourishments to Nutrition and Food Service staff via the computer and diet office. Nutrition and Food Service dietitians work with the Medical Center Nutrition Committee to establish and maintain an enteral nutrition formulary with products that meet the nutrient needs of patients requiring tube feedings and oral nutritional supplements.

Staffing Plan

Food service and production employees are scheduled daily to provide sufficient staff to prepare food, run the trayline, deliver trays and nourishments, wash dishes and perform other sanitation functions. The overall number of employees is based on national VA standards that use the number of meals served and the type of meal service to determine staffing guidelines. Staffing needs for Nutrition and Food Service usually do not change with day-to-day fluctuations in the patient census (i.e. the same number of employees are needed to run the tray line even if the patient census changes moderately, the same number of different menu items is prepared regardless of changes in the daily census). Nutrition and Food Service has both full-time and part-time employees and schedules employees in order to concentrate staff during the peak workload times (tray line and meal delivery). If needed, overtime or unscheduled hours may be used to ensure adequate staffing.

Relationships with Other Services/Support Services:

Health Systems Management, Mental Health, Surgical Care, Primary Care, and Medical Subspecialty Care: The patient care areas provide information such as admissions, discharges, diet orders, late tray requests and other information relating to patient nutrition needs.

Environmental Management

Management of waste products, uniform and linen services, pest control

Engineering

Repair and maintenance services for equipment and utilities

Business

Assistance with timekeeping, payroll, budget, and accounting processes, human resources processes, purchasing contracts, receiving some supplies, equipment purchase

Information

Computer system management and support, medical media support for reproduction requests and medical media equipment for training

Performance and Patient Care Improvement: Assistance with patient safety and quality improvement issues

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OPTOMETRY
Primary Care

Scope of Care

Optometry care at the Kansas City VA Medical Center is the coordinated provision of primary eye care including low vision rehabilitation services to eligible veterans. This care includes the examination, diagnosis, treatment, and management of vision disorders, diseases and conditions of the eye and associated structures, and the diagnosis of related systemic conditions.

Staffing Plan

Clinical Providers: The clinic is staffed Monday through Friday, 8:00 a.m. to 4:30 p.m. by three staff Optometrists and two health techs. The Low Vision Program is staffed with four (4) Social Workers during this same time period.

Requirements for Optometrists:

 Degree from recognized school/college of Optometry
 Current state license
 BLS Certification
 Continuing education for specific state license (20 hours for Kansas and/or 8 hours for Missouri)

Health Technician: The clinic is staffed Monday through Friday, 8:00 a.m. to 4:30 p.m. by two (2) Health Technicians.

Support Staff: Social Workers, Blind Rehabilitation, Ocular Photographer, Optician certified by American Board of Optometry.

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PATHOLOGY AND LABORATORY MEDICINE
Pathology & Lab Service


Scope of Service:

Pathology and Laboratory Medicine seeks to provide a comparable level of high quality care and service to all patients. Our goal is to provide laboratory services in a timely and cost-effective manner, meeting the needs of our patients and their providers. The development and maintenance of active quality improvement, educational and research activities are considered essential in achieving this goal. Personnel of Pathology and Laboratory Medicine are committed and involved in an ongoing process to provide products and services in a manner that will exceed the expectations of our patients and other internal and external customers.

Pathology and Laboratory Medicine provides care for adult and geriatric inpatients and outpatients. Our population consists of 95-98% male patients. Pathology and Laboratory Medicine provides Clinical Pathology and Anatomic Pathology services including specimen processing and testing, interpretative reporting, and consultative interaction. Staff pathologists, medical technologists and technicians, an ancillary testing coordinator, a laboratory information manager and quality assurance coordinator, histotechnologists, a cytology technologist, and clerical personnel perform these services. Pathology and Laboratory Medicine provides routine and emergency service for all patients 24 hours a day, seven days a week.

When staff members are not available to provide and support appropriate patient care needs, the Clinical Chief may obtain assistance through changing and/or adding additional work assignments and outsourcing requested tests/services.

The knowledge and skill levels of Pathology and Laboratory Medicine staff members who provide patient care are maintained through continuing education and training along with annual review of competence in performing scope of practice and annual re-certification or biennial re-privileging.

Pathology and Laboratory Medicine uses various methods to assess and meet patient care needs:

• Peer review
• Review of high risk occurrences
• Staff meeting presentations of data and discussions
• Involvement (at all levels) in performance assessment and improvement
• Consultations (both within and outside the program)
• Daily communication of staff

Standards and guidelines for practice are available for Pathology and Laboratory Medicine. They include but are not limited to the following:

• College of American Pathologists (CAP)
• American Association of Blood Banks (AABB)
• Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
• Clinical and Laboratory Standards Institute (CLSI)
• Centers for Disease Control and Prevention (CDC)
• Department of Veterans Affairs, Veterans Health Administration, VHA Handbook 1106.1
• Food and Drug Administration (FDA)

Staffing Plan

The staffing plan for Pathology and Laboratory Medicine provides coverage 24 hours/day. The 24-hour period is divided into three tours of duty:
1st Shift: 10:00 p.m. - 8:00 a.m.
1-2 Medical Technologists
2nd Shift: 8:00 a.m. - 4:30 p.m.

Laboratory Director (Pathologist)
4 Staff Pathologists
1 Laboratory Manager/Administrative Officer (Medical Technologist)
1 Ancillary Testing Coordinator (Medical Technologist)
1 Automated Data Processing Application Coordinator (ADPAC) and Quality Assurance Coordinator (Medical Technologist)
4 Supervisory Medical Technologists
16 Medical Technologists and Medical Technicians
1 Supervisory Histotechnologist
3 Histotechnologists (includes 1 EM Technologist)
1 Histopathology technician
1 Cytotechnologist

3rd Shift: 4:00 p.m. - 12:00 midnight

1 Supervisory Medical Technologist
2-3 Medical Technologists

Requirements for Staff

Laboratory Director’s Qualifications: Must be a licensed physician, board certified (American Board of Pathology) in anatomic and clinical pathology. Must be credentialed and privileged at the time of their initial appointment and periodically thereafter. Credentialing procedures are outlined in the Medical Staff Bylaws of the medical center. Must meet College of American Pathologists (CAP) and Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) qualifications for Laboratory Director.

Pathologist Qualifications: Must be a licensed physician, board certified (American Board of Pathology) in anatomic and/or clinical pathology. Must be credentialed and privileged at the time of their initial appointment and periodically thereafter. Credentialing procedures are outlined in the Medical Staff Bylaws of the medical center. Must meet College of American Pathologists (CAP) and Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) qualifications for Clinical Consultant.

Laboratory Manager Qualifications: At a minimum, the laboratory manager will meet the requirements for the supervisory medical technologist. The individual must also have demonstrated supervisory and administrative abilities and meet the credentials required by the College of American Pathologists and Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) for General Supervisor.

Ancillary Testing Coordinator Qualifications: The Ancillary Testing Coordinator is a fully qualified medical technologist with at least two years of experience in all areas of laboratory testing. The Ancillary Testing Coordinator advises and assists each Ancillary Testing Site Director, supervisor and all testing personnel. Must meet College of American Pathologists and Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) qualifications for High Complexity testing.

Automated Data Processing Application Coordinator (ADPAC)/Quality Assurance (QA) Coordinator: The ADPAC/QA Coordinator is a fully qualified medical technologist with at least two years of experience in all areas of laboratory testing. The ADPAC/QA Coordinator advises and assists the Laboratory Director, Staff Pathologists, Laboratory Manager, the Section Supervisors, and all testing personnel. Must meet College of American Pathologists and Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) qualifications for High Complexity testing.

Supervisory Medical Technologist Qualifications: Must have completed a full four year course of study, supplemented by at least 12 months in a college or hospital based medical technology program accredited by the American Medical Association’s Committee on Allied Health Education and Accreditation (CAHEA) or have completed a four year course of study that met the requirements for a bachelors or higher degree from an accredited college or university with major study in medical technology, chemistry, or biology. Also the individual must have professional experience or graduate education, or an equivalent combination of both. For GS-11, the requirement is three years of professional experience or three years of graduate education. Must meet requirements of the College of American Pathologists and Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) for General Supervisor.

Medical Technologist Qualifications: Must have completed a full four year course of study, supplemented by at least 12 months in a college or hospital based medical technology program accredited by the American Medical Association’s Committee on Allied Health Education and Accreditation (CAHEA) or have completed a four year course of study that met the requirements for a bachelors or higher degree from an accredited college or university with major study in medical technology, chemistry, or biology. Must meet College of American Pathologists and Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) for High Complexity testing.

Histotechnologist/Cytotechnologist Qualifications: Must have completed a full four year course of study, supplemented by at least 12 months in a college or hospital based medical technology program accredited by the American Medical Association’s Committee on Allied Health Education and Accreditation (CAHEA) or have completed a four year course of study that met the requirements for a bachelors or higher degree from an accredited college or university with major study in medical technology, chemistry, or biology. Must have one year of specialized experience (experience which has equipped the applicant with the particular knowledge, skills and abilities to perform successfully the duties of the histopathology or cytopathology position or Graduate education or an internship which meets the specialized experience required above a GS-5. Must meet requirements of the College of American Pathologists and Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) for Histotechnologist or Cytotechnologist.

Relationship to Other Programs

Specialty services that are clinically necessary and appropriate to this patient population are provided by consultation on a timely basis to all programs. Pathology and Laboratory Medicine provides and/or receives consulting or support services to/from these programs: Primary Care, Surgical Care, Medical Subspecialty Care, Mental Health, and Performance and Patient Care Improvement.

Pathology and Laboratory Medicine receives equipment, supplies, service, or funding from the following programs: Facilities, Information, and Business management.

Pathology and Laboratory Medicine refers tests to outside facilities/agencies for patient care either routinely or for emergent service. These outside services include, but are not limited to:

• Children's Mercy Hospital, Kansas City, MO
• Clinical Resource Center, Veterans Affairs Medical Center, Minneapolis, MN
• Various other Department of Veterans Affairs Medical Centers
• Community Blood Center, Kansas City, MO
• Louis C. Herring and Company, Orlando, FL
• Mayo Medical Laboratories, Rochester, MN
• Midwest Organ Bank, Inc., Kansas City, MO
• Missouri Department of Health, Jefferson City, MO
• Physicians Reference Laboratory, Overland Park, KS
• Quest Diagnostics, St. Louis, MO
• Specialty Laboratories, Inc., Santa Monica, CA
• St. Luke's Regional Laboratories, Kansas City, MO
• Kansas University Medical Center, Kansas City, KS
• Viracor Laboratory, Blue Springs, MO
• Athena Diagnostics, Worcester, MA
• Baylor College of Medicine, Houston, TX

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PHARMACY SERVICE


Scope of Care/Services

The department of pharmacy is dedicated to providing pharmaceutical care, which emphasizes identifying, preventing and resolving medication problems. Pharmacy service has ambulatory and acute care components. Pharmacists participate in all areas. Pharmacists also provide lipid, diabetes, mental hygiene and anticoagulation consultations. Pharmacists interact throughout the day with healthcare providers and patients.

Patients meet with the outpatient pharmacist at the time their prescriptions are filled. The pharmacist evaluates the patient's computer medication profile for medication interactions, duplications, and contraindications and intervenes when appropriate. Also the pharmacist provides appropriate counseling.

Ongoing counseling and direct intervention improves patient compliance with medication treatment regimens and decreases hospital visits for medication related problems. Direct participation by pharmacists at the sites where medication orders or prescriptions are written is a highly cost effective intervention for improving patient outcomes.

Pharmacy service also promotes continuing education for staff and patients. Pharmacists provide in-service training and participate in research as investigators and members of the Human Studies Committee. All investigational agents used in clinical studies are stored in the pharmacy. Members of the pharmacy serve on VISN and hospital P&T committees.

Inpatient Pharmacy Services include:

• Unit Dose/Ward Stock Replenishment
• Controlled substance distribution and accountability
• I.V. admixture preparations
• Chemotherapy
• Investigational drug protocols
• Drug information
• Clinical pharmacy support
• Barcode Medication Administration support
• Pharmacokinetic Drug Monitoring
• Drug utilization evaluations
• Ward inspections
• Discharge medication Counseling
• Medication Profile review
• Drug-Drug, Drug-Food, Drug-dietary supplements interaction monitoring
• Patient allergy/adverse reaction monitoring, reporting, and documentation in record
• Crash cart distribution and accountability

Pharmaceutical support is provided to all staff healthcare providers and patients through the major bed services i.e. Medicine, Surgery, Neurology, Psychiatry, Ambulatory Care, etc.

Outpatient Pharmacy Services include:

• Full prescriptive functions
• Clinical pharmacy support
• Patient medication counseling and education
• Medication profile review
• Interventions
• Investigational drug protocols
• Ward inspections
• Coagulation monitoring/education
• Diabetes monitoring/education
• Lipid monitoring/education
• Methotrexate monitoring/education
• Drug-drug,drug-food interaction
• Patient allergy/adverse reaction monitoring; reporting and documentation in record
• Refill extension
• Polypharmacy reduction

Hours of Operation

• Inpatient pharmacy: 24 hours per day, seven days a week

• Outpatient pharmacy: Monday-Friday 8:00am-5: 30pm

Accessing Services

Pharmaceutical Services are accessed through various Pharmacy Managed Clinics; consults/referrals for participation in the anti-coagulation clinic, lipid, methotrexate and diabetes, by direct patient contact, telephone contact and by prescription generated by staff health care providers.

Staffing/ Types of Positions With-in Pharmacy Service

Chief Pharmacist

• Responsible for the administration of pharmaceutical services in a manner, which provides the highest quality of efficient pharmaceutical care
• Responsible for the overall direction and management of the service including pharmacy resident program

Director, Pharmacoeconomics & Pharmacy Quality Assurance

• Responsible for providing oversight of the formulary management process.
• Responsible for the planning, monitoring and implementation of performance improvement programs within the pharmacy service in cooperation with other pharmacy administration members
• Responsible for coordinating pharmacy resident and student activities
• Oversees the department clinical programs process improvement plans

Director, Clinical Pharmacy Services

• Responsible for the planning, monitoring and implementation of clinical programs within the pharmacy service
• Responsible for coordinating pharmacy resident and student activities
• Oversees the department clinical programs process improvement plans

Director, Pharmacy Operations

• Responsible for the planning, monitoring and implementation of operational programs of pharmacy service
• Responsible for supervision of pharmacy personnel
• Oversees the department operational process improvement plans

Procurement Specialist

• Responsible for purchasing/drug accountability, controlled substances, and automation (currently Baker, Scriptpro, ATC, and Pyxis)
• Responsible for the processing of all drug orders and maintenance of the inventory program.

ADP Coordinator

• Responsible for education/training on all computer packages including VISTA, CPRS, BCMA, and Narcotics
• Creates and maintains pharmacy reporting functions and drug files

Clinical Pharmacy Specialist

• Provide education and monitoring to assigned specialty clinics and inpatient consultation. (Anti-coagulation, diabetes, mental hygiene)
• Identifies, interprets, and resolves prescribing and dispensing issues, including pharmacotherapeutics and the formulary.
• Prescribed drug therapy is evaluated and communicated daily to physicians and other health care professionals for appropriateness, effectiveness, cost-benefit, adverse drug reactions, allergies and disease states

Pharmacists

• Perform clinical and dispensing activity
• Provide drug information and counseling for all outpatients
• Process, recommend and review medication orders
• Provide drug information for all inpatients.
• Prepare and dispense medication
• Conduct counseling, provide drug information

Outpatient Technician

• Supports Pharmacist in managing supply and distribution of all outpatient medications
• Under the supervision of a Pharmacist, provides manufacturing and distribution support utilizing a variety of manual or automatic equipment

Narcotic Technician

• Supports Pharmacist in managing supply and distribution of controlled substances
• Under the supervision of a Pharmacist, provides manufacturing and distribution support utilizing a variety of manual or automatic equipment

Sterile Manufacturing Technician

• Supports Pharmacist in managing supply and distribution of all intravenous medications.
• Under the supervision of a Pharmacist, provides manufacturing and distribution support utilizing a variety of manual or automatic equipment

Inpatient Technician

• Supports Pharmacist in managing supply and distribution of all unit dose medications
• Under the supervision of a Pharmacist, provides manufacturing and distribution support utilizing a variety of manual or automatic equipment

Determinants of Staffing Levels:

Supervisory staff, pharmacists, clinical pharmacy specialists and pharmacy technicians provide pharmaceutical Services. Staffing is determined using workload, error rate, customer complaint, overtime usage, as well as historical and anticipated workload data assuring support of the medical center and pharmacy service mission and goals. Workload and staffing is monitored and adjusted daily and as necessary.

Staffing Plan

Pharmacy Service has established a threshold (minimum) staffing level. Supervisory staff adjusts staffing to meet threshold levels by moving staff from one area to another.

Staff Type Authorized Ceiling Minimum ceiling

Chief of Pharmacy 1 (FTEE) 1(FTEE)

Dir., Pharmacy Operations 1 1

Dir., Clinical Pharmacy Services 1 1

Pharmcoeconmic/QA Pharmacist 1 1

ADP Coordinator 1 1

Procurement Spec. 1 1

Administrative Officer 1 1

Inpatient Pharmacy (FTEE) (FTEE)

Pharmacists 10.9 10.9

Technicians 8 8

Students 1.2 1.2

Outpatient/Clinical Pharmacy

Pharmacists 8.8 8.8

Clinical Pharmacy Specialist 7.0 7.0

Technicians 8 8

Staffing Variance: When staff turnover occurs, contingency plans are activated which address prioritization of service delivery, discontinuation of non-critical activities, adjustment of workload/productivity targets, realignment of staffing resources and rationale for filling vacancies.

Staffing Assignments

Inpatient pharmacy service is provided by pharmacist and pharmacy technicians 24 hours a day, 7 days per week to general medicine, surgery, psychiatry, and oncology. Distribution is supported by unit dose, IV additive, and ward stock replenishment programs. Additional distributive programs involve controlled substances, chemotherapy, total parental nutrition and investigational drug protocols. Data is maintained through the VISTA computer program.

All pharmacists conduct medication profile reviews whenever changes are made to a patient's medication profile. Specifically monitored as part of the provision of pharmaceutical care are patient allergies and adverse events, potential drug-drug, drug-food, drug-dietary supplement interactions, contraindications and incompatibilities. Pharmacists are also responsible, along with other healthcare providers, for documentation in the computer and medical record or reported and observed allergies/adverse reactions.

Core Staffing - Inpatient

Shift 7:00 AM to 3:30 PM

Sun Mon Tues Wed Thurs Fri Sat
Pharmacist 1
Technician 2 2 2 2 2

Shift 7:30 AM to 4:00 PM

Sun Mon Tues Wed Thurs Fri Sat
Pharmacist 1 1 1 1
Technician 1 1 1 1 1

Shift 8:00 AM to 4:30 PM

Sun Mon Tues Wed Thurs Fri Sat
Pharmacist 4.5 4.5 5 4.5 4 1
Technician 2 2 2 1 2 2 2

Shift 8:00 AM to 8:00PM

Sun Mon Tues Wed Thurs Fri Sat
Pharmacist 1 1 1 1 1 1
Technician 1 1 1 1 1 1


Shift 8:30 AM to 5:00 PM

Sun Mon Tues Wed Thurs Fri Sat
Pharmacist 1 1 1 1 1

Shift 10:30 AM to 7:00 PM

Sun Mon Tues Wed Thurs Fri Sat
Technician 1 1 1 1 1

Shift 1:30 PM to 10:00 PM

Sun Mon Tues Wed Thurs Fri Sat
Technician 1 1 1 1 1 1

Shift 2:30 PM to 11:00 PM

Sun Mon Tues Wed Thurs Fri Sat
Pharmacist 1

Shift 4:00 PM to 10:00 PM

Sun Mon Tues Wed Thurs Fri Sat
Technician 1

Shift 11:00 PM to 7:00 AM

Sun Mon Tues Wed Thurs Fri Sat
Pharmacist 1

Shift 8:00 PM to 8:00 AM

Sun Mon Tues Wed Thurs Fri Sat
Pharmacist 1 1 1 1 1 1

Outpatient pharmacy service is provided by staff pharmacists, clinical specialists and pharmacy technicians. This pharmacy is open nine (9) hours daily, Monday through Friday. Patient counseling is performed in clinic areas, outpatient pharmacy counseling areas, and via telephone.

All pharmacists conduct medication profile reviews whenever changes are made to a patient's medication profile. Specifically monitored as part of the provision of pharmaceutical care are patient allergies and adverse reactions, potential drug-drug interactions, drug-food, drug-dietary supplements, contraindications. Pharmacist will intervene when orders appear in appropriate or ambiguous. Clinical pharmacist provides support for the provision of pharmaceutical care. Pharmacists are also responsible, along with other healthcare providers, for documentation in the computer and medical record or reported and observed allergies/adverse reactions.

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PHYSICAL MEDICINE AND REHABILITATION
Clinical Support Service


Scope of Service

Physical Medicine and Rehabilitation (PM&R) care for inpatients and outpatients of all ages. This care includes investigating, treating and consulting on patients needing rehabilitative services. These services include inpatient rehabilitation, physical therapy, occupational therapy, speech pathology, chiropractic care, pain management, telemedicine clinics, and electrodiagnostic testing. In addition, PM&R is an SCI Support center.

Physical Medicine and Rehabilitation offers the following regular hours of patient care operation:

Occupational Therapy/Physical Therapy

Monday – Friday: 7:30 a.m. to 5:00 p.m.
Saturday: On-call

Note: Cascade calling system available after hours and Sunday

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SPEECH PATHOLOGY

Scope of Care

Speech Pathology provides comprehensive diagnostic, counseling, education/training, consultative or treatment services for veterans with communicative disorders. It has as its responsibility, the delivery of the highest quality patient care for communication disorders. This is accomplished through keeping current with the professional literature, training students from affiliated universities, and maintaining exemplary records so that administrative and clinical communication are maximized.

Staffing/Staffing Requirement

The speech pathologist is available all day Monday and during the morning hours on Tuesday through Thursday. The education requirements for the Speech Pathologist include the following:

• Minimum requirement for licensure is the Masters Degree with a one year clinical fellowship/internship
• Ph.D. in Speech Pathology preferred

Services provided currently include diagnosis and treatment of communication disorders to include, but not limited to, the following:

• aphasia
• dysarthria
• apraxia
• dysphonia
• laryngectomy and other aphonias
• impaired cognition
• vocal cord dysfunction
• voice disorders
• dysfluency

Accent reduction treatment also is provided to staff and students as needed.

The clinician is a member of the KCVA medical staff and has an appointment on the Kansas University Inter-campus program. This association provides the staff with the opportunity to supervise and consult involving clinical matters of communication across all ages and need.

The knowledge and skill levels of the staff member providing patient care is maintained through continuing education/training, bi-annual peer review of our medical staff members, and competency assessment of Speech Pathology non-medical staff practitioners.

Staffing

Staffing for Physical Medicine & Rehabilitation/EMG include the following:

• 1 Medical Director
• 1.75 Staff Physicians
• 2 Occupational Therapists
• 6 Physical Therapists
• 1 Physical Therapy Assistants
• 1 Registered Nurse
• 1 LPN
• 1 Social Worker
• 1 EMG Technician
• 1 Chiropractor
• 1 Speech-Language Pathologists

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RADIOLOGY/NUCLEAR MEDICINE
Radiology Service


Scope of Service

Diagnostic, (General, CT, US, MRI and Nuclear Medicine) and Interventional Radiology are provided for our veteran population -- both inpatient and outpatient, male and female, young and old. Special emphasis is placed on our geriatric veteran population. Emergency Services are also provided for non-veterans as deemed appropriate by hospital management. In general, no Therapeutic Nuclear Medicine, Radiotherapy, Mammographic, or PET services are available on-site, but are available via contract and/or Fee Basis process.

All services are available (with the exception of MRI) 24 hours a day, 7 days a week through scheduled tours of duty or an on-call system. Radiology and Nuclear Medicine offers a full range of patient care services between the hours of 7:30 a.m. and 4:30 p.m., Monday through Friday. As stated, there is on-call availability for all sections except MRI; however, emergent services in this area are available through Fee Basis methods. In addition, those services not routinely available or if temporarily unavailable due to staffing or technical difficulties are provided through the medical center Fee Services process.

A priority system for Emergency Room, Triage, and Chemotherapy patients needing diagnostic services is in place. A system also exists for quick identification of patients needing pre-op examinations. Radiographic and Fluoroscopic assistance is also offered to our Operating Room and Gastroenterology Staff on an as needed basis. Diagnostic and ultrasound services are obtainable at bedside if the requesting physician deems the patient’s condition warrants such measures.

Staffing

The Radiology/Nuclear Medicine Service consists of:

• 1 Chief, Radiologists
• 6 Full time Radiologists
• 1 Clinical Coordinator
• 1 Registered Nurse
• 2 Section Supervisors
• 10 Diagnostic Technologists
• 8 Special Procedures Technologists
• 3 Ultra-sonographers
• 1 Lead Nuclear Medicine Technologist
• 2 Nuclear Medicine Technologists
• 1 Information Techician Specialists
• 1 Secretary (OA)
• 1 Health Technician
• 4 Office Automation Assistants
• 2 Medical Support Assistants
• 1 Radiation Safety Technician

Requirements for Staff

Diagnostic and Special Procedures Technologists: The minimum qualifications for all technologists are the following:

• Enrolled in an American Registry of Radiologic Technology (ARRT) approved training program or
• Current American Registry of Radiologic Technology (ARRT) Certification.
• Telephone/Communication skills
• Skilled in the use of DHCP information system

Nuclear Medicine Technologists: The minimum qualifications for all Nuclear Medicine Technologists are the following:

• Current Nuclear Medicine Technology (NMCTB) Certification
• Telephone/Communication skills
• Skilled in the use of DHCP information system
• Knowledge of radiation physics as well as the energies of radionuclides
• Knowledge of radiation and biohazard safety regulations and guidelines of Nuclear Regulatory Commission

Ultrasonographer: The minimum qualifications for all Ultrasonographers are the following:

• Current American Registry of Diagnostic Medical Sonographers (RDMS) Certification
• Telephone/Communication Skills
• Skilled in the use of DHCP information system

Radiologist: The minimum qualifications for a Radiologist are the following:

• A Doctor of Medicine or Doctor of Osteopathy degree
• At least one valid state license to practice medicine
• Completion of training sufficient to satisfy the requirements for certification by the American Board of Radiology or the American Board of Nuclear Medicine.

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RESPIRATORY THERAPY
Medical Sub-Specialty Care


Scope of Service

Respiratory Therapy is a life-supporting, life-enhancing health care profession practiced under qualified medical direction. The Respiratory Therapy Section is under the direction of a board certified pulmonary specialist.

Respiratory care services provided to patients with known or suspected disorders of the cardiopulmonary system include both diagnostic tests and therapeutics. Patient, family and public education are central to the mission of the profession. The Respiratory Therapy Section provides respiratory care 24 hours a day to medical/surgical adult inpatients and patients in the Emergency Department. Outpatients are served on a non-emergent basis Monday thru Friday from 8:00-4:30pm. Discharge training and family education is similarly available.

Therapeutic Services: Therapeutic activities of respiratory therapy include, but are not limited to the following: application of medical gases (primarily oxygen, but including other gases if needed), introduction of pharmacologic agents into the respiratory tract, artificial airway care and provision of mechanical respiratory support (invasive and non-invasive) and broncho-pulmonary hygiene (suction, postural drainage and percussion and other forms of chest physiotherapy).

The Respiratory Therapy Section will be responsible for providing, nebulized aerosol treatments, metered dose inhaler treatments, postural drainage and percussion to patients. Respiratory Therapy will also be available to set up and administer any oxygen therapy required in these patient care areas.

Therapeutic Services in MICU and SICU include the following:

• Ventilator Support – Invasive and non-invasive: Respiratory Therapy will provide both invasive (via endotracheal tube or tracheostomy tube) as well as non-invasive (via nasal or face mask) ventilator support to patients in MICU and SICU as requested by physician staff. Therapists will assist with establishment of artificial airway as directed by the physician in charge; however, responsibility for placing an artificial airway will be with physician in charge or with a nurse anesthetist under the supervision of a physician. The respiratory therapist will be responsible for monitoring the cuff pressure on endotracheal tubes and ensuring that the tube is appropriately secured. The physician in charge will determine ventilator settings.

• Suctioning: Suctioning of intubated patients will be a joint responsibility of Respiratory Therapy and Nursing staff in the Intensive Care Units. Therapists, following administration of all aerosol or metered dose treatments on intubated patients, will perform suctioning routinely.

• Frequency Of Treatments: In the Intensive Care Units or in the Progressive Care Unit (PCU), aerosol treatments will be administered at any frequency ordered by the physician staff including continuous or hourly therapy. Outside of these special care units, aerosol treatments will be administered as frequently as every 2 hours. Patients requiring more frequent treatments should be transferred if possible to a special care unit in order to manage the higher acuity respiratory illness.

Diagnostic activities: Diagnostic activities of respiratory therapy include, but are not limited to, obtaining and analyzing biologic specimens related to the respiratory tract (e.g., arterial blood gas samples, tracheal suctioning for secretions, etc). In addition, physiologic evaluations, such as monitoring of weaning parameters in mechanically ventilated patients, are performed as requested by the Medical Staff.

Other specific diagnostic services include:

• Arterial Blood Gases
• Wright Peak Flow Measurement
• Bedside measurement of FEV1 and FVC
• Formal Pulmonary Function Studies (Spirometry, lung volumes, Dlco)
• Ventilator Weaning Parameters (NIF,TV, RR, VE)
• Pulse Oximetry (rest and exercise)
• Sputum induction

Other services related to or concomitant with these duties include providing respiratory therapy during cardiopulmonary resuscitation and transporting critically ill patients within the medical center. In addition, therapists are responsible for all appropriate charting (BCMA and CPRS notes) and record filing as well as providing appropriate equipment maintenance and repair.

Other services provided by the Respiratory Therapy Sections include the following:

• Home Oxygen/Sleep Program: A respiratory therapist or Advanced Practice Nurse is also be assigned to provide support for all patients requiring home oxygen or home CPAP/BiPAP equipment for management of medical problems. This support will include making all necessary arrangements for setting up and delivery of this equipment and follow-up and re-certification of medical necessity for this equipment.

• Pulmonary Function Laboratory: A respiratory therapist or pulmonary function technician will be assigned to the Pulmonary Function Laboratory from 7:30-4:00pm on Monday thru Friday. The therapist will have demonstrated competency in performing Pulmonary Function Studies including spirometry, lung volume measurements by body plethysmograph and nitrogen washout methods, lung diffusing capacity measurements, and measuring response to bronchodilator treatments.

• Evaluation of Exercise Tolerance – This will be accomplished by measurement of arterial oxygen saturation and heart rate with exertion.
• Education – Patients will be provided with all appropriate educational materials including, but not limited to, material on smoking cessation, breathing techniques, and nutritional counseling with regard to weight loss or improving nutritional status.

Advance Practice Nurses currently assigned to the Pulmonary will provide additional support for the rehabilitation services of the Respiratory Therapy Section.

Requirements for Staff:

All individuals who provide diagnostic or therapeutic respiratory care will have appropriate qualifications and training. All Respiratory Therapy staff must demonstrate a basic level of competency to perform the basic duties required for care of patients.

Staffing Plan for Respiratory Therapy

Respiratory Therapy is staffed 24 hours a day, seven days a week. All Respiratory Therapists will be utilized to staff the Intensive Care Units. A registered or certified respiratory therapist will always be available to provide assistance in the Intensive Care Unit if this is required.

Respiratory Therapy is staffed in three shifts comprised of Day (8:00-4:00pm), Evening (4:00pm-12:00am), and Night (12MN-8:00am). The minimum number of therapists assigned to each shift will be as follows:

Day shift: 3 Therapists
Evening shift: 2 Therapists
Night shift: 2 Therapists

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SPECIAL PROCEDURES
Medical Subspecialty Care


Scope of Care

The Special Procedure staff provides care to patients who receive conscious sedation during the performance of special procedures. These procedures include invasive and/or non-invasive radiologic procedures, endoscopy, colonoscopy, bronchoscopy, ERCP, liver biopsy, cardioversion, Trans-esophageal echo, MRI, bone marrows aspiration, and insertion of permanent pacemaker.

The care provided includes:

• Assessment of patient
• Monitoring of patients
• Recovering patients
• Nursing intervention
• Patient teaching

Patient Care Delivery System

As all RNs are equally competent in all areas, assignments are made on a weekly rotation basis. Only Registered Nurses from other critical care areas such as ICU and ER who have completed the conscious sedation in-service and competencies may float to, or provide coverage for special procedures.

The GI LPN’s provide technical assistance for endoscopic and diagnostic services within the GI section which include colonoscopy, EGD, ERCP, EUS, FNA, flexible sigmoidoscopy, liver biopsy, electrocautery, treatment of acute hemorrhage, and polypectomy techniques.

Basic standards of care are:

• The patient will demonstrate stability in CV, respiratory and neurological systems
• The patient will be free of injury and be in a safe environment.
• The patient will experience reduction in anxiety.
• The patient will experience minimal pain and discomfort.
• Patient/significant other will be able to explain and discuss specific instructions.
• Outpatient and/or significant other will participate in discharge planning.

Requirements for Staff

The basic requirements for Special Procedure RN Staff include:

• Current State Licensure as a Registered Nurse
• BCLS Certification
• ACLS certification
• Successful completion of the Critical Care Course
• Successful completion of Special Procedure Orientation
• Completed competency checks on:
• IV Therapy
• Airway Maintenance and Management
• Defibrillation
• Arrhythmia Detection
• System Assessment

The basic requirements for the GI LPN Medical Instrument Technicians:

• Successful completion of GI technician orientation
• Current state licensure as a licensed practical nurse
• BCLS certification
• IV certification

Staffing

The minimum level of nursing staff is eight (8) RNs, who work overlapping tours, from 0630-1730 Monday-Friday.

The minimum level of instrument technician staffing is five (5) technicians. Shifts are staggered to better accommodate the department needs from Monday - Friday as follows:

• 0600-1430
• 0700-1530
• 0730-1600

One (1) GI LPN is on-call on off tours, weekends, and holidays.

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ANESTHESIOLOGY SERVICE
Surgical Care

Definition:

Anesthesiology is the art and science of rendering a patient insensible to pain by the administration of anesthetic agents and related drugs and procedures. Anesthesia and peri-operative care represents those services, which anesthesia professionals provide upon request, assignment or referral, most often to facilitate diagnostic, therapeutic or surgical interventions. In other instances, the referral or request for consultation or assistance may be for management of acute or chronic pain.

Anesthesia providers practice according to their expertise and institutional policy. Anesthesia and peri-operative care is administered in four general categories: (1) pre-anesthetic preparation and evaluation, (2) daily OR management and surgical scheduling (3) anesthesia induction, maintenance and emergence, and (4) postanesthetic care and recovery. Other services include perianesthetic and clinical support functions, critical care medicine, and pain management.

Scope of Care

The scope of care includes, but is not limited to the following:
A. Performing and documenting a pre-anesthetic assessment and evaluation of the patient, including requesting consultations and diagnostic studies, selecting, obtaining, ordering, or administering pre-anesthetic medications and fluids, and obtaining informed consent for anesthesia.
B. Developing and administering an anesthetic plan, which may include general, regional, or local anesthesia, and intravenous sedation.
C. Selecting, obtaining, or administering the anesthetics, adjuvant drugs, accessory drugs, and fluids necessary to manage the anesthetic, to maintain the patient’s physiologic homeostasis, and to correct responses to the anesthetic or surgery.
D. Selecting, applying or inserting appropriate noninvasive and invasive monitoring modalities for collecting and interpreting patient physiological data.
E. Appropriately managing a patient's airway.
F. Managing emergency and recovery from anesthesia by selecting, obtaining, ordering, or administering medications, fluids, or ventilatory support in order to maintain physiologic homeostasis to provide relief from pain, anesthesia side effects, and to prevent or manage complications.
G. Releasing or discharging patients from a post anesthesia care area and providing post-anesthesia follow-up evaluation and appropriate care.
H. Ordering, initiating, or modifying pain relief therapy, through the utilization of appropriate diagnostic and therapeutic modalities.
I. Responding to cardio-pulmonary emergency situations.
J. Consultative care for the critically ill.
K. Consultative services for pain management.

Staffing Requirements

Anesthesia Department is staffed Monday through Friday, 7:00am – 3:30pm, but services are available on call 24 hours-a-day, 7 days-a- week.

Education Requirements

Anesthesiologist

• Graduate from an accredited medical school
• Current license
• Certification by the American Society of Anesthesia

Certified Registered Nurse Anesthetist

• Graduate from a accredited nursing anesthesia program
• Current license
• Certification by ANNA

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GENERAL SURGERY SERVICE
Surgical Care

Scope of Care

The scope of practice of General Surgery includes diagnosis, preoperative, operative, and postoperative management in the following specific areas:

 Alimentary tract
 Abdomen and its contents
 Breast, skin, and soft tissue
 Endocrine system, including thyroid, parathyroid, adrenal, and endocrine pancreas
 Surgical oncology
 Complete care of critically ill patients with underlying surgical conditions
 Care of wounds secondary to diabetes, neuropathy, and pressure

Staffing

The staff consists of 2.5 FTEE: two full-time physicians, one 0.5 part-time physicians, and three residents.

Education Requirements

Physician

• Completion of accredited residency
• Board eligible or board certified in General Surgery

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NEUROSURGERY SERVICE
Surgical Care

Scope of Care

Patients needing neurosurgical care will be provided fee-based care as is essential to that patient’s medical condition.

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OPHTHALMOLOGY SERVICE
Surgical Care


Scope of Care

Ophthalmology care at the Kansas City VA Medical Center is the coordinated provision of primary eye care in conjunction with the Optometry Service as well as the provision of many, but not all, tertiary eye care services. This care includes the examination, diagnosis, treatment and management of vision disorders, diseases, and conditions of the eye and associated structures, and the diagnosis of related systemic conditions. It also includes conventional and laser surgery for many ocular conditions that require these treatments. It is, additionally, the pathway for access to more specialized ophthalmic services, which would include evaluation, diagnosis and treatment by specialists, as well as access to diagnostic and therapeutic modalities that are not available at this institution.

Ophthalmology service will deliver high-quality eye care to eligible veterans in an efficient and compassionate manner that is cost-effective and timely as much is possible. Eye and vision services will be carried out in coordination with Optometry Service.

Staffing/Staffing Requirements

The staff consists of 1.25 FTEE: one full-time staff, one .25 part-time staff, and two residents.

Education Requirements

Physician

• Completion of accredited residency
• Board eligible or board certified ophthalmologist

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ORAL SURGERY
Surgical Care


Scope of Care

Complete oral surgical care is provided to all veterans legally entitled to oral surgery care as determined by the dental eligibility office. Medical patients needing oral surgery will be provided fee-based care as is essential to that patient’s medical condition.

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ORTHOPEDIC SURGERY
Surgical Care


Scope of Care

The scope of practice includes the care of all bones, joints, tendons, ligaments, and muscle injuries, including fractures, lacerations, tumors and infection; congenital deformities, and arthritic problems. This service specializes in trauma, general orthopedics, hand, total joint replacement, spine and sports medicine.

Staffing Requirements

The staff consists of 4.175 FTEE: one full-time physician, one .625 part-time physician, two .25 part-time physicians, two full-time Physician Assistants. The residency program provides three (3), 5th, 4th and 2nd year residents.

Education Requirements

Physician

• Completion of accredited residency
• Board eligible or board certified in Orthopedic Surgery

Physician Assistant

• Physician Assistant Degree
• Certification by NCCPA
• Licensure or eligible for licensing as a Physician’s Assistant in the United States

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OTOLARYNGOLOGY SERVICE
Surgical Care

Scope of Care

This specialty deals with the diagnosis and treatment of congenital and acquired disease(s) of the ear, nose, throat, head and neck region. It also deals with the diagnosis and medical surgical treatment of cosmetic deformities in the head and neck region.

Staffing Requirements

The staff consists of 1.25 FTEE: one full-time Physicians’ Assistant, one 0.375 part-time surgeon, two contract physicians, and residents.

Education Requirements

Physician

• Completion of accredited residency
• Board eligible or board certified otolaryngologist

Physician Assistant

• Physician Assistant Degree
• Certification by NCCPA
• Licensure or eligible for licensing as a Physician’s Assistant in the United States

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PLASTIC SURGERY SERVICE
Surgical Care

Scope of Care

Plastic Surgery is a field divided into Cosmetic and Reconstructive Surgery. It is the reconstructive surgical element that the Kansas City VA Medical Center will be promoting.

Reconstructive Surgery involves the repair of parts of the body that have been deformed by birth defects, trauma or acquired disease. Examples of birth defects are cleft lip and palate, protruding and prominent ears, birth defects of the hands (syndactyle), and feet.

Reconstructive surgery also involves the restoration of deformities caused by traumatic events, e.g., acute burns, disfiguring burn scars from motor vehicle accidents, and other acts of trauma. Disfiguring surgical procedures for cancer - for example head and neck cancer and breast cancer- can also be reconstructed using plastic surgical techniques.

Staffing Requirements

The staff consists of .625 FTEE: one 0.625 part-time physician and one resident.

Education Requirements

Physician

Completion of accredited residency
Board eligible or board certified in Plastic Surgery

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PODIATRY SERVICE
Surgical Care

Scope of Care

The practice of podiatry is the diagnosis, therapeutic, orthotic or palliative treatment and prevention of disease, disorders or dysfunctions of the foot, and includes the muscles, tendons, ligaments or other soft tissue structure directly attached to the anatomical foot and which impacts on or affects the foot or foot function and osseous structure up to and including the articulating surfaces of the ankle joint.

Staffing Requirements

The staff consists of 1 FTEE.

Education Requirements

Physician

• Completion of accredited residency
• Board eligible or board certified in Podiatry

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UROLOGY SERVICE
Surgical Care

Scope of Care

This is the branch of medicine concerned with the physiology and pathology of the urogenital tract.

Staffing Requirements

The staff consists of 2.75 FTEE: one full-time physician, three 0.25 part-time physicians, one full-time physicians’ assistant, and three residents.

Education Requirements

Physician

• Completion of accredited residency
• Board eligible or board certified in Urology Surgery

Physician Assistant

• Physician Assistant Degree
• Certification by NCCPA
• Licensure or eligible for licensing as a Physician’s Assistant in the United States

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VASCULAR/ THORACIC SURGERY
Surgical Care

Scope of Care

Thoracic Surgery and Vascular Surgery are two separate services in almost all institutions. At the Kansas City VA, two board-certified thoracic and cardiovascular surgeons cover both thoracic and vascular surgery and are on call every other day. The institution is thereby able to realize significant economies of scale. KCVAMC does not perform cardiac surgery at the present time.

Work-Load

The service performs about 350 major and minor, vascular and thoracic surgical procedures annually. They also provide inpatient care for nearly 200 angiograms performed each year. This involves significant interaction and coordination with the interventional radiology department. The recent addition of an office assistant is a tremendous help in this function.

The vascular lab has been closed for over five years. All non-invasive vascular tests, (ABI’s/PVR’s), are performed at other institutions on contract or fee-basis. With the recruitment of a medical technologist, these tests will once again be available at the KCVAMC. This will meet the urgent need of the referring physicians and also realize significant cost savings. The current workload will increase as we anticipate at least 300 to 500 tests annually.

The service has four operation days - Monday, Tuesday, Thursday, and Friday. The OR runs from 7:30am to 3:30pm but no new operations are started after 2:00pm. As a teaching institution, on an average, two operations - one major and one minor - are performed each operation day.

Wednesday is devoted to outpatient clinics and conferences. There are four multidisciplinary patient care and teaching conferences, namely: Vascular, Thoracic, Oncology, and Morbidity and Mortality conference.

At the present time the service has two outpatient clinics: a vascular wound clinic on Monday afternoon and a general clinic on Wednesday. With the recent recruitment of two physician assistants, additional clinics may be possible in the future, especially long term follow-up clinics, which were not possible before due to inadequate staff. With the additional staff, the service also plans to re-institute its research activities.

The services also provides support to the other institutions in the western orbit of VISN 15 for tertiary care in thoracic and vascular surgery, especially in areas such as the endovascular surgical treatment of abdominal aortic aneurysms (AAA). Additional staff and resources will be required if this referral work increases in the future.

Staffing Requirements

The staff consists of a total of five FTEE’s: two full-time thoracic and cardiovascular surgeons, two fully qualified and certified physician assistants, a medical technologist for the vascular lab and an office assistant. In addition, two residents from KUMC rotate through the service: one Chief Resident and one intern.

Education Requirements

Surgeons

• Board eligible or board certified in Thoracic and Vascular or Cardiovascular surgery
• License to practice in the USA

Physician Assistant

• Physician Assistant Degree
• Certification by NCCPA
• Licensure or eligible for licensing as a Physician’s Assistant in the United States

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PERI-OPERATIVE SERVICES
Surgical Care

Scope of Care

This area includes six (6) major operating room suites, one (1) Urology surgical suite, one (1) Urology office procedure room, and a Minor Operating Room designated for local anesthetic procedures. The average census for inpatients and outpatients is 320 per month with 75% of these cases categorized as outpatient procedures. All major subspecialty procedures are performed except open heart and organ transplantation surgery.

Staffing Requirements

Requirements for the RN staff include:

• Current state licensure
• Successful completion of annual mandatory in-services
• Current BLS Health Care Provider certification
• Successful completion of a designated until specific competency task(s)
• Successful completion of Nursing and Operating Room orientation programs

The length and intensity of orientation are determined by the individual’s prior surgical experience. Nurses without surgical experience are required to have a minimum of one-year experience on a Medical-Surgical ward or in an Intensive Care Unit. Competency is maintained by VAMC or community education and by unit in-services.

Requirements for all other staff include:

• Current BLS Health Care Provider certification
• Successful completion of annual mandatory topics
• Successful completion of a designated Service competency task
• Successful completion of Nursing and Operating Room orientation programs

Patient Care Delivery System

The Operating Room utilizes team nursing to incorporate the standards of care defined by AORN, JCAHO, OSHA, and other regulatory agencies that are applicable. The Nurse Manager or a designee makes assignments of patient care. Assignments reflect the degree of procedure difficulty and equitable rotation of staff through all subspecialties. RNs with a special interest or expertise in a surgical subspecialty will act as section coordinator and scrub or circulate in the area as frequently as possible. All RNs and scrub technicians rotate on call. Two (2) staff members are assigned to each case – one each to circulate and scrub. One (1) nurse is acceptable to staff the minor operating room and local cases, which are done in a major suite. Two (2) staff members are assigned to the Urology Office Procedure Room for P&Cs. When a scrub tech and an RN are assigned together, the RN will always circulate.

The Nurse Manager is in charge of the Operating Room and will make decisions when conflicts are unresolved after consultation with surgeons and anesthesia staff. The Nurse Manager is responsible for problem resolution involving the nursing staff and the Chief of Surgery for problem resolution involving the surgeons and anesthesia staff.

Staffing

The staff consists of 15.2 FTEE; 11 full-time RNs, two part-time RNs, four health technicians. The regular tour of duty for the RN’s and health technicians is 0700-1530 Monday through Friday with call.

Two (2) staff members are assigned to on-call each day. The health technicians are each assigned a major area of responsibility (instrument/supplies, patient transportation, OR assistance) and several ancillary tasks. The on-call tour of duty is from 1530 to 0700 of the following day. On weekends and holidays, call is covered for 48 hours and 24 hours respectively.

Physician Support: The services of the surgeon and anesthesia services are available 24 hour a day, 7 days a week.

Pharmacy: Pharmacy services are available 24 hours a day. Ward stock is delivered as needed. A clinical pharmacist is available for consultation and to provide education services to patients/staff via phone or pager.

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POST ANESTHESIA CARE UNIT
Surgical Care

Scope of Care

The PACU is a nine-bed unit located in close proximity to the operating room and the SICU and operates 10 hours per administrative day. Patients requiring recovery outside these hours are recovered in the SICU. The nurses in these units provide concentrated and comprehensive care necessary in the immediate post anesthesia period for patients who have had surgical, diagnostic or therapeutic procedures.

The scope of peri-anesthesia nursing practice involves the assessment for, diagnosis of, intervention for, and evaluation of physical or psychosocial problems or risks for problems that may result from the administration of sedation/analgesia or anesthetic agents and techniques. Our practice is systematic in nature and includes the nursing process, decision-making, analytical and scientific thinking, and inquiry. Our unique knowledge base regarding sedation/analgesia and anesthetic agents and techniques, the physiological and psychological responses to them, and the vulnerability of the patient subjected to them is coupled with all the principles of medical-surgical and critical care nursing.
Post-anesthesia Phase I: The nursing roles in this phase focus on providing post-anesthesia nursing care to the patient in the immediate post-anesthesia period, transitioning them to Phase II, in the in-patient setting, or to an intensive care setting for continued care. Basic life-sustaining needs are of the highest priority and constant vigilance is required during this phase as the needs of the patient are neither minimal nor episodic.

Special procedures in the PACU include:

• Arterial line insertion
• Swan-Ganz line insertion
• Intubation
• External pacemaker use
• Transvenous pacemaker monitoring
• Administration of vasoactive medications
• Thrombolytic therapy
• Code Blue (cardio-pulmonary arrest) management
• ECT done in PACU by anesthesia

Patient Care Delivery

The method of care delivery in PACU is specialized patient care based on individual assessment and potential risks from anesthesia and surgical procedures. P ACU standards of care are initiated for each patient and specific protocols are implemented as necessary.
The PACU charge nurse assigns patient care in the P ACU in relation to patient needs, individual expertise and geographic location of the patient.
The Critical Care Nurse Manager schedules sufficient critical care registered nurses to provide quality nursing care, to assure prompt recognition of changes in the patients' condition and to make appropriate intervention.
The PACU is staffed with 3 RNs who work overlapping tours to provide l0-hour coverage. SICU staff as needed provides additional staffing. Critical Care Health Technicians provide escort and ECG services.

Requirements for Staff

Requirements for the RN staff include

• Current state licensure
• Current BLS Health Care Provider certification
• ACLS Certification
• Complies with VA policies and procedures regarding competence.
• Competence-based orientation and annual review practice
• Successfully completed critical care course or mastered its content
• Successful completion of Critical Care orientation, critical care content and critical care skills checklist
• Successful completion of PACU-specific orientation
• Phase I PACUs are by their nature critical care units, and as such staff should meet the competencies required for the care of the critically ill patient. These competencies should include, but are not limited to, ventilator management, hemodynamic monitoring and medication administration, as appropriate to their patient population.

Competent Support Staff

Under the supervision of the peri-anesthesia RN, the competent peri-anesthesia support demonstrates knowledge, skills and behaviors to maintain a consistent level of practice. Peri-anesthesia competent support staff demonstrates competencies that include, but not limited to, the following:

Requirements for Health Technicians:

• Current BLS Health Care Provider certification
• Completed hospital and unit orientation
• Completion of Nursing Assistant training
• Completion of EKG training
• Completion of phlebotomy training
• Completed all mandatory classes

Staffing Plan

Patient Classification/Recommended Staffing Guidelines

• Staffing is based on patient acuity, census, and physical facility.
• The professional nurse uses prudent judgment in determining nurse-to-patient ratios and staffing mix to reflect patient acuity and nursing intensity.
• Phase I PACU recommendations is a minimum of 2:1 (two patients per RN); less if the patient is unstable.
• Phase II PACU ration is 3:1 (three patients per RN) unless patient is unstable.

Post Anesthesia Phase
Phase I Level of Care

The professional peri-anesthesia nursing roles during this phase focus on providing post anesthesia nursing care to the patient in the immediate post anesthesia period, and transitioning them to Phase II level of care, in the inpatient setting, or to an intensive care setting for continued care.
CLASS 1:2 - One Nurse to Two Patients
• One unconscious, stable, without artificial airway, and over the age of 9 years; and One conscious, stable and free of complications.
• Two conscious, stable, and free of complications
• Two conscious, stable, 11 years of age and under; with family or competent support staff present.
CLASS 1:1 - One Nurse to One Patient

• At the time of admission, until the critical elements are met.
• Requiring mechanical life support and/or artificial airway.
• Any unconscious patient 9 years of age and under.
• A second nurse must be available to assist as necessary.
CLASS 2:1 - Two Nurses to One Patient

• One critically ill, unstable, complicated patient.
Phase II Level of Care

Two licensed nurses, one of whom is an RN competent in Phase II post anesthesia nursing, are present whenever a patient is receiving Phase II level of care. An RN must be present at all times during Phase II.
Physician Coverage: There is physician coverage during hours of operation, including internal medicine, medical subspecialties, surgeons and anesthesiologist during administrative hours, including subspecialties.
Respiratory Therapy: Respiratory therapists provide scheduled respiratory treatments and respiratory care in emergent/life threatening situations during hours of operation.
Dietician: Dieticians are available by consult.
Clerical Support: Clerical support is available during hours of operation.
Pharmacy: Pharmacists is available during hours of operation via phone or pager. Ward stock is delivered on a routine basis.
Social Workers: Social workers from the Transition Team are available to provide psychosocial care and discharge planning services. During non-administrative hours, there is an on-call Social Work available.
Discharge Planning: Discharge planning services are provided by the Transition Team. Members of the Transition Team include Social Workers and RN's.
Chaplain: Chaplains are available for spiritual care of patients.

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TRANSITION TEAM
Clinical Support Service


Scope of Care

The goal of the Transition Team is the monitoring and implementation of processes and activities to maximize the coordination of care within the continuum of care. Service coordination and delivery of care can begin before admission and continues through the hospital stay to include discharge planning and post hospital follow-up. Key to this monitoring and care coordination is the interdisciplinary treatment planning and assessment process carried out by the following Transition Team members based on the veteran’s changing needs.

Social Workers: Social Workers assist with the development of psychosocial database and social histories, psychosocial assessment and psychosocial diagnoses, and treatment planning for patients. This care or treatment may be provided in (a) individual or group therapies to include marital or grief counseling and family therapy, or (b) through education by providing information or referral services. This may occur at discharge, aftercare planning, or in crisis intervention.

Chaplains: Chaplains provide supportive services to aid in the total care and treatment of patients in primary care, community nursing homes, hospices, etc. The pastoral ministry may be to individual patients, or to the patients and their families in crisis situations. They conduct religious worship services, and conduct funerals. They assist with bereavement counseling, patient education, and with pastoral/spiritual assessments.

Nursing Staff: Nursing care focuses on the nursing process, infection control, patient/family education, and discharge planning. Complexity of care and qualifications of staff, as identified in their performance standards, are the basis for patient care assignments.

Staffing Plan

Days Evenings Weekends

Social Worker 10 1 On Call * 1 On Call *
(Note: * A Social Worker rotates call with other Product line Social Workers)


RN 6 By phone ** By phone **
(Note: A Registered Nurse is available by phone cascade; call Operator or Nursing Sup)


Chaplain 2 1 On call 1 On call
(Note: Two full-time Chaplains and one part-time Chaplain provide pastoral care. They are on station in three to four hour segments and on call the remaining hours.)

Requirements for Staff

Social Worker: All Social Workers are professionally prepared and qualified to provide services by having a Master’s Degree in Social Work from a graduate school accredited by the Council on Social Work Education (CSWE). Social Workers will have met additional qualifications required for employment in the Veterans Administration as a professional Social Worker. The Social Worker is also responsible for meeting state licensure and other relevant professional and ethical requirements as specifically applied to practicing staff at this facility.

Chaplain: All Chaplains must be ordained, have a BA or BS degree and BD or Masters of Divinity, and three years of full-time clergy experience after ordination. He/She must have an ecclesiastical endorsement from an officially recognized endorsing body of their religious community.

Registered Nurse:

• Current state license
• BLS Health Care Provider Certification
• Successful completion of annual mandatory services
• Successful completion of a designated unit specific competency task(s)

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SUPPORT SERVICES FUNCTIONS


Medical Subspecialty Care

Medical: Medical officer of the day can be contacted between the hours of 1630 and 0800 via telephone or pager

Respiratory Therapy: Respiratory therapy provides 24-hour coverage for scheduled respiratory treatments and for emergent/life threatening situations. Each unit has an assigned therapist available via pager.

Primary Care

Dental: Dental services are provided to inpatients to deal with acute situations eight (8) hours a day, five days a week. Service is initiated via telephone.

Surgical Care

Surgical officer of the day can be contacted between the hours of 1630 and 0800 via telephone or pager.

Mental Health

Psychiatric Officer of the Day can be contacted between the hours of 1630 and 0800 via telephone or pager.

Recreational Therapy: Recreation therapy is provided on the unit. A recreation therapist attends report with the multidisciplinary team and chart rounds each week. The therapist can be contacted personally or by phone to provide service.

Clinical Support

Dietary Services: Dietetic services are provided to patients via a consult to provide diet education and to deal with nutrition/food service problems as needed.

Chaplain: Chaplains are available for spiritual care of patients 24 hours a day.

Rehab Services: Rehab services are available to assist inpatients affected by neurological conditions or trauma to maintain optimal level of functioning. Services of a Rehab Medicine Physician, PT, OT, Speech Pathology, Chiropractic Care, Pain Management, and EMG are available on consult.

Prosthetics: Prosthetics services are available via an authorized care provider computer consult generated referral during normal business hours.

Pathology and Laboratory

Laboratory provides specimen analysis service to assist in the diagnostic assessment and evaluation of individual patients.

Radiology

Radiology services for x-rays, CT scans, MRI scans, ultrasound and nuclear medicine are available 24-hours-per-day, seven days a week, either as in-hospital or fee basis.

Information Services

The computer system ties together the many departments of the hospital, providing a communication pathway for tests and procedures and obtaining their results, progress notes, health summaries, inpatient discharge summaries, operation reports, consults, etc.. The computer communication system enables scheduling various tests/labs/ procedures and accessing the results. The computer access is available 24 hours a day with numerous terminals at each nursing station, in resident rooms and offices. Coverage for computer related issues is available either by phone or page 24 hours a day.

The File Room is open from 0730 – 1600 and has staff available to pull patients’ medical records when needed.

Facilities

Environmental Services: Patient care areas are maintained at a high level of cleanliness. Services to patient care areas include management of waste products, especially regulated medical waste; providing sufficient amounts of clean serviceable bed linens, uniforms and surgical linens; and rigid accountability of patients effects and valuables that are not maintained on the ward by nursing staff or sent home with family members. Additional services include terminal bed cleaning, pest control, signage and furniture moves.

Engineering: Patient care areas have access to a trouble call phone number for needed mechanical repairs. Additional staff may be called in during off tours as necessary. Staff members have continuous access to a computer work order system.

Mechanical And Electrical Safety: Electrical/mechanical preventive maintenance and inspection of equipment will be provided by Biomedical Engineering. Any equipment that has been dropped, physically damaged, presents evidence of overloading, or has a damaged power cord or plug is removed from service. Any electrical device that suggests abnormal operation is discontinued from use, and the problem is reported to Biomedical Engineering.

Business

Supplies: Total Supply Support (TSS) services are available 0745 - 1615 for supply needs. House Supervisor to be notified for needs after hours. Supply needs are available through SPD. Dialysis supply room is routinely stocked 3X per week with availability by phone. At night, the Nursing Supervisor covers SPD and supplies are obtained on an emergency basis.

Fiscal: Assistance during administrative hours is provided for issues regarding payroll, salary, wage and leave usage, timekeeping, and fee basis.

Performance & Patient Care Improvement

Infection Control: The Infection Control Nurse acts as a consultant in matters related to Infection Control. She/he is available during administrative hours by phone or pager.

Patient Safety: The Patient Safety Manager acts as a consultant in matters related to patient safety. She/he is available via telephone or pager during administrative hours.
QI/UM/RM: A QARN is available during regular business hours and acts as a resource person in matters pertaining to quality improvement, utilization review, and risk management.

Customer Relations: A Patient Representative is available, by pager, to provide support and assistance to patients and employees between 7 a.m. and 5:30 p.m., Monday through Friday.

Education

Learning Resource: Reading material is available by mobile book cart. Medication information and information regarding specific issues is available in the Patient Health Education Resource Center.

Safety and Health

The Safety Office staff act as consultants for safety and health matters. Safety Office staff are available during administrative hours and by pager during off-tours, weekends, and holidays. Patient care units must adhere to Safety and Health Policies. Material Safety Data Sheets are available in each unit. In the event of large-scale disaster, the Emergency Management Plan will be followed.


VA Police: The police are available by telephone/radio page 24 hours per day to assist staff with volatile situations involving patients, visitors, and staff; will also assist with locating missing patients.

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IN-PATIENT SERVICES 3 WEST


Scope of Care

This 26-bed unit specializes in the delivery of comprehensive medical and surgical care of patients who are under the care of the following surgical sub-specialties: general surgery, vascular/thoracic surgery, orthopedics, urology, ENT, and neurosurgery. Significant subgroups of patients are under the care of plastic surgery, ophthalmology, and oral surgery. Clientele is adult and geriatric inpatients, predominately male. Patient care focuses on direct patient care, education of the patient and the patient’s family, and ensuring safety for the patients, visitors, and staff.

Patient Care Delivery

A combination of collaborative and total patient care is utilized to meet patient care needs. The Charge Nurse or Nurse Manager will do assignment of patient care on day shift. The off tour assignments are made by the Charge Nurse. Assignments are based on the patients' physical/educational needs and take into account family involvement. Assignments also consider the skill levels of the staff, supervision required, and the patients' classification. Standards of care have been developed that address the basic needs of patients on a service wide scope. Additional standards of care focusing on ANA guidelines serve as the guidelines for care. Patient care needs are assessed on a regular basis and standards monitored for conformance and quality of care.

Requirements for Staff

Requirements for the RN staff include:

• Current state licensure
• Current BLS Health Care Provider certification
• Completed hospital wide orientation
• Completed unit orientation
• Completed all mandatory classes
• Completed unit specific competencies on care of the surgical patient

Requirements for the LPN staff include:

• Current state licensure
• Current BLS Health Care Provider certification
• IV certification
• Completed hospital wide orientation
• Completed unit orientation
• Completed all mandatory classes
• Completed unit specific competencies on care of the surgical patient

Requirements for Health Technician requirements include:

• Current BLS Health Care Provider certification
• Completed hospital and unit orientation
• Completed all mandatory classes
• Completed unit specific competencies on care of the surgical patient
• Completion of Nursing Assistant training
• Completion of ECG training
• Completion of Phlebotomy training

Staffing Plan

The staff ceiling for 3 West is based on providing six and one half (6.5) nursing hours per patient day (NHPPD) for an average daily census of 17 patients. The NHPPD used for this unit was benchmarked against community hospitals. Daily staffing will be a minimum of five (5) NHPPD.

Usual Staffing Pattern

3– 5 on Nights with at least 2 licensed staff. One of the licensed staff must be an RN.
4– 10 on Days with at least 2 licensed staff. One of the licensed staff must be an RN.
3– 7 on Evenings with at least 2 licensed staff. One of the licensed staff must be an RN.

Adjustments in staffing will be made based on patient acuity by the Inpatient Coordinator, Nurse Manager or Nursing Supervisor. Agency staff, Fee-basis staff, or overtime may be used to ensure adequate staffing. Use of agency and fee-basis staff will follow established nursing policies.

Physician Coverage: There is 24-hour physician coverage, including internal medicine, medical subspecialties, and surgeons, including subspecialties.

Respiratory Therapy: Respiratory therapists provide scheduled respiratory treatments and respiratory care in emergent/life threatening situations 24 hours a day.

Dietician: Dieticians are available by consult.

Clerical Support: Clerical support is available 24-hours-a-day.

Social Workers: Social workers from the Transition Team are available to provide psycho/social care and discharge planning services. During non-administrative hours, there is an on-call Social Worker available.

Discharge Planning Team: Discharge planning services are provided by the Transition Team. Members of the Transition Team include Social Workers and RN’s.

Chaplain: Chaplains are available for spiritual care of patients 24 hours a day.
Pharmacy: Pharmacist is available 24 hours a day via phone or pager. Ward stock is delivered on a routine basis.

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IN-PATIENT SERVICES 8W

Scope of Care

This 25-bed medical/surgical unit serves as the base unit for Oncology, General Medicine, and ENT services. Care is also provided to a diverse group of patients with medical diagnoses. Special services focus on patients requiring telemetry, pain control, chemotherapy, tracheostomy care, and terminal/palliative care.

Patient Care Delivery

The Nurse Manager or a charge nurse, Monday through Friday, makes assignments on the day tour. On evening, night and weekend tours, assignments are made by the charge nurse. Assignments are based on the patients' physical/educational needs and take into account family involvement. Assignments also consider the skill levels of the staff, supervision required, and the patients' classification. Standards of care have been developed that address the basic needs of patients on a service wide scope. Additional standards of care focusing on ANA and OCN guidelines serve as the guidelines for care. Patient care needs are assessed on a regular basis and standards monitored for conformance and quality of care.

Requirements for Staff

Requirements for the RN staff include:

• Current state licensure
• Current BLS certification
• Completion of hospital wide orientation
• Completion of unit orientation
• Completion of all mandatory classes
• Completion of specific competencies on the care of the oncology patient

Requirements for LPN include:

• Current state licensure
• Current BLS Health Care Provider certification
• IV Certified
• Completion of hospital wide orientation
• Completion of unit orientation
• Completion of all mandatory classes
• Completion of unit specific competencies on the care of the oncology patient

Requirements for HT include:

• Current BLS Health Care Provider certification
• Completion of hospital and unit orientation
• Completion of Nursing Assistant training
• Completion of ECG training
• Completion of Phlebotomy training
• Completion of all mandatory classes
• Completion of unit specific competencies regarding the care of the oncology & telemetry patient

Staffing Plan

The staff ceiling for 8 West is based on providing six and one half (6.5) nursing hours per patient day (NHPPD) for an average daily census of 16 patients. The NHPPD used for this unit was benchmarked against community hospitals. Daily staffing will be a minimum of five (5) NHPPD.

Usual Staffing Pattern

3– 4 on Nights, there are at least 2 licensed staff. Two of the licensed staff must be a RN.
4– 8 on Days, there are at least 2 licensed staff. Two of the licensed staff must be a RN.
3– 4 on Evenings, there are at least 2 licensed staff. Two of the licensed staff must be a RN.

Adjustments in staffing will be made based on patient acuity by the Nurse Manager or Nursing Supervisor. Agency staff, Fee-basis staff, or overtime may be used to ensure adequate staffing. Use of agency and fee-basis staff will follow established nursing policies.

Physician Coverage: There is 24-hour physician coverage, including internal medicine, medical subspecialties, and surgeons, including subspecialties.

Respiratory Therapy: Respiratory therapists provide scheduled respiratory treatments and respiratory care in emergent/life threatening situations 24 hours a day.

Dietician: Dieticians are available by consult.

Clerical Support: Clerical support is available 24-hours-a-day.

Social Workers: Social workers from the Transition Team are available to provide psycho/social care and discharge planning services. During non-administrative hours, there is an on-call Social Worker available.

Discharge Planning: Discharge planning services are provided by the Transition Team. Members of the Transition Team include Social Workers and RN’s.

Chaplain: Chaplains are available for spiritual care of patients 24 hours a day and by consult.

Pharmacy: Pharmacists are available 24 hours a day via phone or pager. Ward stock is delivered on a routine basis.

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IN-PATIENT SERVICES 8 EAST

Scope of Care

8 East is a 24-bed complex medicine unit. Admissions are usually from but not limited to Blue Team, Green Team, Red Team, and Neurology. Turn over rate is generally three days to one week. Pateint population is primarily adult and geriatric inpatients, and predominantly male.

Special services particular to this unit include care of patients with the following diagnoses:

• COPD
• Complications of diabetes
• Neurological disorders
• Renal hemodialysis

Patient Care Delivery

The Nurse Manager or designee assigns the care of the patient on day shift. The off tour assignments are made by the Charge Nurse. Assignments are based on the patients' needs and the skill level of the staff. The plan of care is developed to address the need of the patient. The standard of care is based on the guidelines of ANA. Patient care needs are assessed on a regular basis and plans of care are modified to the patient’s needs.

Requirements for Staff

The basic requirements for the RN staff include:

• Graduate of an accredited school of nursing
• Current state licensure
• Completion of formal hospital and unit-specific orientation program
• Current in BCLS
• Completion of mandatory competencies
• Completion of unit specific competencies
o Pain management
o Restraint use
o Care of central lines
o Care of chest tube

LPN requirements include:

• Graduate from accredited school
• Current licensure
• Current BCLS certification
• Certification in IV therapy
• Completion of unit orientation
• Completion of mandatory training
• Completion of unit specific orientation program

Health Technician requirements include:

• Current BCLS certification
• Phlebotomy certified
• EKG certified
• Completion of unit level orientation
• Completion of all mandatory training

Certified Nursing Assistant (CNA)

• Current BCLS certification
• Completion of unit level orientation
• Completion of all mandatory training


Clerical Support is provided on a 24-hour basis to inpatient wards to:

• Transcribe physician’s order
• Maintain inpatient records.

STAFFING PLAN

The staff ceiling for 8 East is based on providing 6.5 nursing hours per patient day (NHPPD) for an average daily census of 21.24 patients. The NHPPD used for this unit was benchmarked against community hospitals. Daily staffing will be a minimum of five (5) NHPPD. There is an ongoing evaluation at the end of each tour to allow for adjustments.

Usual Staffing Pattern

3– 4 on Nights with at least 2 licensed staff. One of the licensed staff must be an RN.
4– 8 on Days with at least 2 licensed staff. One of the licensed staff must be an RN.
3– 4 on Evenings with at least 2 licensed staff. One of the licensed staff must be an RN.

Adjustments in staffing will be made by the Nurse Manager, or designee, or Nursing Supervisor based on patient acuity . Agency staff, Fee-basis staff, or overtime may be used to ensure adequate staffing. Use of agency and fee-basis staff will follow established nursing policies.

Clerical Support: Clerical support is available 24 hours-a-day.

Physician Coverage: There is 24-hour physician coverage.

Social Workers: Social workers from the Transition Team are available to provide psycho/social care and discharge planning services. During non-administrative hours, there is an on-call Social Worker available.

Discharge Planning Team: Discharge planning services are provided by the Transition Team. Members of the Transition Team include Social Workers and RN’s.

Chaplain: Chaplains are available for spiritual care of patients 24 hours a day

Dietician: Dieticians are available for nutritional care.

Pharmacy: Pharmacist is available 24 hours a day via phone or pager. Each ward is assigned a Registered Pharmacist who is available Monday through Friday during administrative hours. Unit-dose medications are replenished on a daily basis and/or as necessary for patient needs.

Medical & Surgical Specialty Services: Consult services are available on on-call basis. These services include all surgical, medical, and nursing specialties.

Respiratory Therapy: Respiratory therapists provide scheduled respiratory treatments and respiratory care in emergent/life threatening situations 24 hours a day.

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ACUTE INPATIENT PSYCHIATRY 10 West

Scope of Care

This is a 25 bed unit specializing in the care of acutely, mentally ill patients. The major diagnoses consist of depression, schizophrenia, bipolar affective disorder, and substance abuse. There are provisions available for female veterans. Psychiatrists, residents, nurses, and social workers make up the three treatment teams. Patients are assigned to the teams based on their mental health primary care team assignment. Psychology services are provided on a consultant basis.

The unit provides a therapeutic milieu to help patients organize and structure their personal lives. The components of this milieu are assessments, community meetings, individual and group psychotherapy, pharmacotherapy, recreational therapy, patient levels of responsibility and interdisciplinary treatment teams.

Special services particular to this unit include:

• Crisis intervention (with a quiet seclusion/restraint room)
• Electroconvulsive Therapy (ECT)
• Drug/Alcohol education
• Group therapy including medication education, health awareness, orientation group, relaxation group, goal group, community meeting, crafts group, current affairs group, substance abuse group, spirituality group and process groups

The multidisciplinary treatment plan is initiated upon admission and reviewed weekly during chart rounds. The focus of treatment is to relieve the crisis and plan care to support the patients’ strengths and weaknesses during the remainder of the hospitalization and after discharge. The average length of stay on the acute unit is 8 to 10 days.

Involuntary commitment via reading the patients’ rights within three hours is provided in the ward areas.

Requirements for Nursing Staff

Requirements for the RN staff include:

• Current state licensure
• Completion of Prevention and Management of Disruptive Behavior
• Completion of unit based competency skill (Alco-sensor review)
• Completion of service wide mandatory requirements
• Current CPR certification

Requirements for LPN staff include:

• Current state licensure
• Completion of Prevention and Management of Disruptive Behavior
• Completion of unit based competency skill (Alco-sensor review)
• Completion of service wide mandatory requirements
• Current CPR certification

Requirements for NA include:

• Completion of Prevention and Management of Disruptive Behavior
• Completion of unit based competency skill (Alco-Sensor review)
• Current CPR Certification

Delivery System

Care is delivered via the hospital wide standards of care. A minimum of two patient specific standards of care is implemented at the time of admission and is updated at least weekly. Additional standards are initiated to ensure holistic care is provided.

A combination of team nursing and total patient care are used to deliver care within the unit. There is a Nurse Manager assigned and a minimum of two RN's and two other team members during the day tour. During the evening tour, there is an RN Charge Nurse, one other RN and two team members, and during the night tour there is an RN Charge Nurse and two other team members.

Assignments

The Nurse Manager or Charge Nurse makes assignments. Assignments will reflect the degree of supervision needed by the individual and patient needs, the technology used and geography of the unit. Assignments are to follow practices outlined in the Nursing Service Policy and Procedures Manual. The RN responsible for making these assignments will be familiar with these policies and procedures and will review them as necessary to keep his/her information current.

Staffing Plan

The staffing plan is based upon the number of hours required for direct patient care during a 24-hour period. After benchmarking with the community and other VA Medical Centers with similar units, it was determined that the average number of direct patient care hours per 24 hours be 5.5 hours per patient day. The 5.5 hrs/24 hrs. was divided, with two hours of direct patient care for day/evening shift and 1.5 hours per patient day.

Of course, this staffing plan is dependent upon acuity level, staffing mix, available staff and is continuously monitored 24/7 by Nurse Manager and Nursing Supervisor to maintain standard of care.

Mental Health Provider: Patient's psychiatrist is available via phone or pager. Psychiatric officer of the day can be contacted between the hours of 1630 and 0800 via telephone or pager.

Social Work: Social work services are provided by social workers based on the unit. The social worker attends multidisciplinary team meetings, gathers psychosocial data and conducts family meetings. Services are available via telephone or pager.

Psychologist: Psychologists provide biopsychosocial therapies. Psychologists attend multidisciplinary team meetings and conduct family meetings.

Pharmacist: The mental health clinical pharmacist is available for the unit during the administrative tour for consultation. A pharmacist is available 24 hours via phone or pager.

Clerical Support: Clerks provide clerical coverage during working hours. On evenings, weekends and holidays, clerical personnel are available by pager to assist with transcription of orders. Admission coverage 24 hours a day is available in the primary care areas.

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MEDICAL INTENSIVE CARE UNIT/CORONARY CARE UNIT


Scope of Care

The Medical Intensive Care Unit (MICU) has eleven (11) private rooms, which provide specialized acute care for the critically ill adult patient 24 hours a day. The MICU also serves as the Coronary Care Unit. Most frequent medical diagnoses treated include: Acute MI, CHF, dysrhythmia, DKA, COPD, septic shock, and GI bleed.

Special procedures performed in these areas include:

• Cardioversion
• Intubation
• External pacemaker use
• Transvenous pacemaker monitoring
• Swan-Ganz line insertion
• Arterial line insertion
• Code Blue (Cardio-pulmonary arrest) management
• Dialysis (Hemo and Peritoneal)
• Administration of vasoactive medications

Patient Care Delivery

The method of care delivery is total patient care. Critical Care standards, based on the patient's primary diagnosis, are initiated for each patient and specific protocols are implemented as necessary.

Requirements for Staff

Requirements for the RN staff include:

• Current state licensure
• BLS Health Care Provider and ACLS Certification
• Successful completion of critical care orientation, special procedures, critical care content and critical care skills checklist.
• Completion of critical care competencies

Requirements for Health Technician requirements include:

• Current BLS Health Care Provider certification
• Completed hospital and unit orientation
• Completed all mandatory classes
• Completed unit specific competencies on care of the surgical patient
• Completion of Nursing Assistant training
• Completion of ECG training
• Completion of Phlebotomy training

Staffing

The Critical Care Clinical Coordinator schedules sufficient critical care registered nurses to provide quality nursing care, to assure prompt recognition of changes in the patient's condition, and to make appropriate intervention. Staffing is based on patient acuity and census and in accordance with Nursing Service Policy Memorandum 118-15.

Assignments

A designated charge nurse makes assignments. Assignments will reflect the level of expertise of the staff member, the patient's needs, the technology used, and the geography of the unit.

Staffing Plan

NURSING: The staff ceiling for the ICUs is set by using 12 hours per patient day, a value obtained using benchmarked information. The average daily census of nine (9) is used as the patient day component of the calculation. When the census goes over the ADC, overtime, agency, fee-basis and intermittent staff are used to provide adequate coverage.

The ceiling allows for an average of one (1) nurse to two (2) patients 24 hours per day. The individual nurse to patient ratio is established by patient need. Those patients who require 1 to 1 care receive it; others may only need a ratio of 1 to 3. The health technicians provide transport, ECG, and phlebotomy services. They also assist the nursing staff in providing basic nursing care for the critical care patients. Actual staffing for MICU will be no less than 12 hours per patient day.

Physician Coverage: There is 24-hour physician coverage, including internal medicine, medical subspecialties, and surgeons, including subspecialties.

Respiratory Therapy: Respiratory therapists provide scheduled respiratory treatments and respiratory care in emergent/life threatening situations 24 hours a day.

Dietician: Dieticians are available by consult.

Pharmacy: Pharmacist is available 24 hours a day via phone or pager. Ward stock is delivered on a routine basis.

Clerical Support: Clerical support is available 24 hours a day.

Social Workers: Social workers from the Transition Team are available to provide psycho/social care and discharge planning services. During non-administrative hours, there is an on-call Social Worker available.

Discharge Planning: Discharge planning services are provided by the Transition Team. Members of the Transition Team include Social Workers and RNs.

Chaplain: Chaplains are available for spiritual care of patients 24 hours a day.

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SURGICAL INTENSIVE CARE UNIT

Scope of Care

The SICU is a ten-bed multi-specialty unit specializing in the care of the critically ill adult. Interdisciplinary teams provide immediate to intermediate post-operative critical care, respiratory therapy including ventilatory support, pain management, hemodynamic monitoring and cardiac monitoring 24 hours a day. Complicated surgical cases of varying specialties comprise the most frequent diagnoses in this area.

Special procedures in the SICU include:

Arterial line insertion
Swan-Ganz line insertion
Intubation
External pacemaker use
Transvenous pacemaker monitoring
Administration of vasoactive medications
Thrombolytic therapy
Code Blue (cardio-pulmonary arrest) management
Dialysis (Hemo and Peritoneal)

Patient Care Delivery

The method of care delivery in SICU is total patient care. Critical Care standards based on the patient’s primary diagnosis are initiated for each patient and specific protocols are implemented as necessary. A designated charge nurse makes assignments in SICU. Assignments will reflect the level of expertise of the staff member, the patients' needs, the technology used and the geography of the unit.

The Critical Care Clinical Coordinator schedules sufficient critical care registered nurses to provide quality nursing care, to assure prompt recognition of changes in the patients' condition and to make appropriate intervention. Based on patient acuity and census, staffing is continuously reviewed and adjusted as warranted.

Requirements for Staff

Requirements for the RN staff include:

• Current state licensure
• BLS Health Care Provider certification (ACLS Certification to be phased in 2001-2002)
• Successful completion of Critical Care orientation, critical care content and critical care skills checklist
• Successful completion of PACU-specific orientation

Requirements for HT include:

• Current BLS Health Care Provider certification
• Completed hospital and unit orientation
• Completion of Nursing Assistant training
• Completion of ECG training
• Completion of Phlebotomy training
• Completed all mandatory classes

Staffing Plan

NURSING: The staff ceiling for the ICUs is set by using 12 hours per patient day, a value obtained using benchmarked information. The average daily census of seven (7) is used as the patient day component of the calculation in SICU. When the census goes over the ADC, overtime, agency, fee-basis and intermittent staff are used to provide adequate coverage.

The ceiling allows for an average of one (1) nurse to two (2) patients 24 hours per day. The individual nurse to patient ratio is established by patient need. Those patients who require 1 to 1 care receive it; others may only need a ratio of 1 to 3. The health technicians provide transport, ECG, and phlebotomy services. They also assist the nursing in providing basic nursing care for the critical care patients. Actual staffing for SICU will be no less than 12 hours per patient day.

Physician Coverage: There is 24-hour physician coverage, including internal medicine, medical subspecialties, and surgeons, including subspecialties.

Respiratory Therapy: Respiratory therapists provide scheduled respiratory treatments and respiratory care in emergent/life threatening situations 24 hours a day.

Dietician: Dieticians are available by consult.

Clerical Support: Clerical support is available 24-hours-a-day.

Pharmacy: Pharmacist is available 24 hours a day via phone or pager. Ward stock is delivered on a routine basis.

Social Workers: Social workers from the Transition Team are available to provide psycho/social care and discharge planning services. During non-administrative hours, there is an on-call Social Worker available.

Discharge Planning: Discharge planning services are provided by the Transition Team. Members of the Transition Team include Social Workers and RN’s.

Chaplains: Chaplains are available for spiritual care of patients 24 hours a day.

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PROGRESSIVE CARE UNIT


Scope of Care

The Progressive Care Unit (PCU) is a seven-bed unit, all private rooms, which provides care (24-hours a day) for adult patients requiring nursing care on a concentrated and continuous basis or long term patients.

Specialized care provided includes therapies such as antiarrhythmic drug administration, cardioversion and telemetry monitoring. Special procedures include Cardioversion & Temporary Transvenous Pacemaker care.

Patient Care Delivery

The method of delivery is total patient care. PCU Nursing Standards, based on the patient's primary diagnosis, are initiated for each patient and specific protocols are implemented as necessary.

A designated charge nurse makes assignments. Assignments will consider the patient's needs as well as the geography of the unit and the staff members’ expertise.

Staffing

The Critical Care Clinical Coordinator schedules at least three (3) RNs per tour to provide quality nursing care. The PCU staff ceiling, 14 RN’s, provides 24-hour coverage. In addition to the core, a health technician is provided Monday through Friday during administrative hours for additional support. If patient care needs require additional staffing, that staff is provided through overtime, pulls from the ICU staff, or agency use.

Requirements for Staff

Requirements for the RN staff include:

• Current state licensure
• BCLS and ACLS Certification
• Successful completion of critical care content, critical care skills checklist, and special procedure orientation.

Requirements for HT include:

• Current BLS Health Care Provider certification
• Completed hospital and unit orientation
• Completion of Nursing Assistant training
• Completion of ECG training
• Completion of Phlebotomy training
• Completed all mandatory classes

Physician Coverage: There is 24-hour physician coverage, including internal medicine, medical subspecialties, and surgeons, including subspecialties.

Respiratory Therapy: Respiratory therapists provide scheduled respiratory treatments and respiratory care in emergent/life threatening situations 24 hours a day.

Dietician: Dieticians are available by consult.

Clerical Support: Clerical support is available 24-hours-a-day.

Social Workers: Social workers from the Transition Team are available to provide psycho/social care and discharge planning services. During non-administrative hours, there is an on-call Social Worker available.

Discharge Planning: Discharge planning services are provided by the Transition Team. Members of the Transition Team include Social Workers and RN’s.

Chaplains: Chaplains are available for spiritual care of patients 24 hours a day.

Pharmacy: Pharmacist is available 24 hours a day via phone or pager. Ward stock is delivered on a routine basis.

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AMBULATORY (OPT) CARE SERVICES


AMBULATORY SURGERY UNIT (ASU)
Surgical Care


Scope of Care

The Ambulatory Surgery Unit is a 4-recliner, 3-stretcher unit. Services provided include pre-operative care and level II recovery to surgical patients and care post cardiac catheterization and post myelogram. The clientele is adult and geriatric, outpatients, predominantly male, eligible veterans.

Requirements for Staff

Registered Nurse

• Current state licensure
• Current BLS Health Care Provider certification
• Completion of Level II Recovery Competency, RN
• Minimum of one year experience in acute care med/surg setting

LPN Staff

• Current state licensure
• Current BLS Health Care Provider certification
• Completion of Level II Recovery Competency, LPN (1997)
• Minimum of one year experience in acute care med/surg setting
• IV certification

Staffing

Nursing: Three (3) RNs and one (1) LPN provide patient care. The ASU is open Monday through Friday, except holidays from 0600 to 1830.

Clinical Providers: Physician providers (surgeons, consulting medical specialties, and anesthesiologists) are available on call.

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EMERGENCY ROOM
Primary Care

Scope of Care

The Emergency Room provides urgent and/or emergent assessment, care and education provided in a ten-bed, level III Emergency Room. The Emergency Room is staffed 24 hours-a-day commensurate with the needs of the patient population served. The care provided is most often for unscheduled patients. The assistance of consult services, i.e., psychiatry, special care, etc, is available to support the staff. Some procedures are performed in the ER; those are listed in Policy Memorandum 11C-05.

Requirements for Staff

Clinical Providers: The Emergency Room Staff will have satisfactorily completed training in Internal Medicine or Surgery beyond the PGY-3 and 4 levels. All such physicians will have current BLS/ACLS certification and be appropriately credentialed as an emergency care provider according to the Medical Staff By-laws on Credentialing and Privileging.

Nursing Staff

Registered Nurse

• Current state licensure
• ACLS Healthcare Provider certification
• Successful completion of Critical Care Course
• Successful completion of Mandatory Reviews
• Completed competency checks on:
o Drawing arterial blood gases
o External pacing
o Performing pacing
o Testing visual acuity
o Administering 02 therapy
o Recognizing dysrhythmia

Health Technician

• BCLS certification
• Completed competency checks
• Blood pressure
• EKG

Staffing Plan

Clinical Providers: Emergency staffing will be physicians who have satisfactorily completed
training in Internal Medicine or Surgery beyond the PGY-3 and 4 level. Upon proper credentialing and privileging for ER work, the Program Director for Primary Care and/or the Director of Emergency Services Department will provide staff and AOD physicians with orientation specific to the ER. Emergency Room will be staffed with a physicians 24 hours/7 days per week.

Nursing: Staffing is adjusted based on ER census and acuity level, and is reviewed each shift, seven days a week. The coverage is for the 24-hour period. There is a Nurse Manager five days a week on the day tour. There is also a Charge Nurse assigned on all tours. Core staffing is as follows:

TYPE Mon – Fri Weekends Mon – Fri Weekend Mon – Fri Weekend
TYPE Nights Nights Days Days Evenings Evenings
RN 1 1 2.5 2.5 2.5 2.5
HT 1 1 1 1 1 1

Clerical Support: During the 8:00 a.m. – 12:00 a.m. tour Monday through Friday, and weekend, there is a secretary stationed in the ER. There is a minimum of one AOD on duty during nights.

Chaplain: Provides support to patients to meet spiritual needs and provides emotional support during crisis and as needed on an on-call basis.

Social Work: A social worker is available during administrative hours to provide social work related services to patients as needed and during off hours on on-call basis.

Pharmacy: Pharmacy services are available 24 hours-a-day. A clinical pharmacist is available to provide educational services to patients.

Respiratory Therapy: A respiratory therapist is available 24 hours-a-day, 7 days-a-week via pager for emergent problems.

Medical & Surgical Specialty Services: Consult services are available to the ER on on-call basis. These services include all surgical, medical, and nursing specialties.

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COMPENSATED WORK THERAPY (CWT)

COMPENSATED WORK THERAPY/SUPPORTED EMPLOYMENT (CWT/SE), COMPENSATED WORK THERAPY/TRANSITIONAL RESIDENCE (CWT/TR)

Scope of Care:

The Compensated Work Therapy program (CWT) provides opportunities to participate in varying levels of working environments conducive to practicing normal work behaviors. Barriers to achieving normal work behaviors are addressed and interventions are utilized to achieve successful work behaviors. In addressing the therapeutic needs to specific populations of veterans served by Mental Health, CWT provides a variety of work environments, as well as specialized therapeutic modalities and staffing to achieve therapeutic results. Within CWT, which serves a population of veterans that present with substance abuse recovery issues, veterans with psychiatric issues that do not manifest in psychoses, severe depression or severe anxiety disorders and veterans with medical rehabilitation issues, the program offers a workshop environment on the hospital grounds, as well as transitional work environments that are in private sector businesses. Participants can work in a work environment that is appropriate to their level of performance with the ultimate goal of achieving full time gainful employment.

Patient population served:

• Primarily those patients with substance abuse histories and/or other psychiatric disorders that are actively engaging in a recovery process.
• Who are employable in terms of lacking significantly limiting physical or psychiatric issues and demonstrate motivation to address such issues.
• Are homeless or are in unstable housing situations.

The Compensated Work Therapy/Supported Employment (CWT/SE) program works with a specific population of veterans who are considered to be Seriously Mentally Ill (SMI). These veterans present with psychosis, severe mood disorders with psychotic features, severe anxiety disorders with psychotic features and have little recent history of employment and who are primarily supported by benefits from various agencies. The treatment model is to place the veteran in employment, provide whatever supports are necessary to sustain the employment, to find and coordinate resources that can be utilized for the supports that are necessary and to provide these supports as long as needed. Staffing provides more intensive case management to fewer veterans with average caseloads of 15 veterans per provider. Therapeutic issues involve coordination of benefits so the veteran understands ultimately that if s/he achieves full time employment that benefits will be affected and/or terminated. By law that establishes CWT/SE veterans will not lose their benefits while participating in CWT/SE but are subject to benefit adjustments if s/he is released from CWT/SE because they have achieved their ultimate level of employment.

Patient population served:

• Patients who qualify as having Serious Mental Illness.
• SMI’s that express a desire to obtain employment.

The Compensated Work Therapy/Transitional Residence Program (CWT/TR) is a 30-bed residential program for the vocational rehabilitation and community reintegration of veterans who are homeless and have substance abuse and/or other psychiatric histories. CWT/TR veterans must be enrolled in the CWT program for a sustained period of time to participate in CWT/TR. The program elements include vocational assessment/counseling, Compensated Work Therapy (CWT)/transitional employment, sobriety maintenance, skill building, and assessment, development of independent living skills for successful community reintegration. The emphasis is on re-establishment of autonomous daily living skills that are fundamental to total community reintegration.

Patient population served:

• Veterans who are capable of participating full time in the Compensated Work Therapy Transitional Work Experience (TWE) program.
• Veterans who have an understanding of sobriety maintenance and recovery and have demonstrated this through sustained periods of sobriety utilizing recovery and aftercare programming.
• Veterans who have significant barriers to employment and community reintegration which can be resolved through agreements and/or negotiated settlements.
• Veterans who are capable of living independently with minimal need of structured daily routines and can negotiate daily living skills in a productive manner.
• Veterans who are homeless, eminently homeless and/or who need a therapeutic environment that will allow them to practice sober behaviors and engage in a peer therapeutic community as their support system.

QI Monitors:

QA monitors are through the Northeast Program Evaluation Center (NEPEC). The monitor involves collecting data at admission and at discharge. All CWT programs are rated in the same areas by comparative data.

The CWT/SE program is also evaluated every 6 months by expert consultant review utilizing a fidelity scale for supported employment services as defined by US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMSHA), and their Evidence-Based Practices for Supported Employment.

The CWT/TR program utilizes the following monitors:

• Monitoring of successful reintegration into the community as measured by > 90% of veterans are employed at discharge.
• Monitoring of successful reintegration into the community as measured by > 90% of veterans are housed at discharge.
• Monitoring of successful reintegration into the community as measured by > 90% of veterans are maintaining their sobriety at discharge as verified through ongoing random urine drug screens (UDS) and random breathalyzer sampling.

The CWT/TR QA monitors are conducted as scheduled through the Northeast Program Evaluation Center (NEPEC). The monitor involves collecting data at admission, at 3 months, at discharge and at 3 months after discharge. Specific issues assessed are substance abstinence, shelter and employment.

STAFFING:

CWT: CWT/SE

.48-CWT/TR Administrative Manager Supervisory VRS
1-CWT Manager VRS
1-CWT Transitional Employment Coord. VRS
1-CWT/SE Coordinator VRS
3-CWT/SE Employment Specialists VRS

CWT/TR:

.41- CWT/TR Administrative Manager Supervisory VRS
1-CWT/TR Manager VRS
1-CWT/TR NEPEC Coordinator Addiction Therapist

ASSIGNMENTS:

The focus of the staff is on:

• recovery stabilization,
• development, management and placement of participants in CWT working environments,
• job carving for veterans with SMI.
• therapeutic and administrative management of patient care in working environments, and
• fiscal and administrative management of business activities relating to those environments.
• coordination of care for participants with both internal and external resources needed to achieve veteran’s therapeutic goals.
• The focus of the CWT/TR staff is recovery stabilization, maintenance, vocational adjustment and community reintegration through development of ADLS (autonomous daily living skills).

The therapeutic community focus of the CWT/TR program emphasizes that elected “team-leaders” rotate and provide coverage to the residence on Saturday and Sunday. There is also a live-in house manager that is on duty from 12:00 midnight to 8:00 a.m. on all nights of the week.
The Mental Health Program also provides a person on-call for emergency situations and emergency coverage on all hours not covered by professional staff. The staff on-call is notified of any irregular incidents, as defined by the TR policy guidelines, and provides necessary support as required.

The TR building has an ADT Security system that is monitored by ADT who will respond to any emergencies that are activated through the security and fire monitoring system. The building is put on activated alarm status for security of intrusion or extrusion from 12:00 midnight to 5:00 a.m. Any entry or exit from the building will set off an audible alarm in the building and will automatically notify ADT Security of such activity. In such instances the Kansas City Missouri Police Department will respond to any activities. Fire alarms go directly to the KCMO Fire Department with immediate response.

Support Services From Other Product Lines

Mental Health Program

CWT/SE participants often share resources and interact in case management resources and services with the Mental Health Intensive Case Management (MHICM) program.

CWT/SE participants also participate in Research studies performed by psychiatrists. These studies provide monitoring of the veterans vital signs and reporting of outcomes based on the study.

Primary Care Program

Emergency Room: Utilized as needed in addressing injuries in the CWT program.

Medical: Done on PRN and on 6 month scheduled appointments.

Dental: Provided on PRN basis as ordered.

Specialty Care Program

As ordered by a physician through consultation on an as needed basis for CWT participants.

Diagnostic & Rehabilitative Care

Rehabilitative Medicine: As needed and is utilized for performing functional assessments on participants to determine level of limitation. Provide PT and OT services as needed.

Prosthetics: Done by physician-generated referral through Primary or Specialty Care.

Laboratory: Lab services are utilized as requested by a physician or a PA. UDS are processed and results are provided through laboratory services.

Radiology: Provided as ordered by physician referral.

Performance & Patient Care Improvement Program

QI/UR/RM: QMS is available during administrative hours for quality improvement, utilization review issues, and/or risk management issues.

Safety Officer: Provides routine fire and safety drills and inspections. Provides guidance in safety related issues.

Industrial Hygienist: Provides guidance in HazMat issues. The Industrial Hygienist provides inspection and overview of HazMat issues, such as MSDS libraries and hazardous material spills.

VA Police: Available by phone/pager 24 hours/day to assist in all issues of security.

Information

Library: Available to all CWT participants during library hours. CWT participants can utilize these information services according to their working schedules. Internet access is also provided.

Information Resource Management (IRM): Provide hospital wide consolidated database support for all CWT staff. Includes DHCP (Decentralized Hospital Computer Program)/Encounter (Electronic Medical Record software), as well as a variety of standard and specialized software packages that can be used in a network environment. IRM provides a process that insures confidentiality of patient information, when followed.
IRM provides training and technical support to all CWT staff as requested.

Facilities

Pharmacy: All physician and PA ordered medicines are provided through pharmacy. Medications can be picked up at the outpatient pharmacy.

Engineering: Provides support services for utilities as requested through electronic work orders. Engineering provides repair and maintenance to property to insure integrity.

Environmental Management: Provides housekeeping products for CWT building. Environmental Management provides guidance in utilization of housekeeping products.

Business

Total Supply Support: Provides contractual guidance and services as requested for the acquisition of services and goods.
TSS provides guidance as needed in contractual agreements dealing with VAAR and FAAR areas.
TSS provides contractual services for expansion or construction cost to the CWT building.

Fiscal: Provides administrative management support for all financial transactions in the CWT program. This includes payment to veterans through payroll issuance, coordination and deposit of accounts receivable, coordination and management of accounts payable and statistical and accounting information for all required fiscal reports of the CWT program.

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DAY TREATMENT CENTER

Scope of Care

The Day Treatment Center (DTC) is a psychosocial rehabilitation program that provides a range of mental health treatment services which assist in the support and rehabilitation of adults with severe and persistent mental illness. Services are designed to maximize independent functioning, promote recovery, increase coordination and collaboration in all aspects of the treatment planning process and crisis intervention. Ultimately they help to reduce inpatient hospitalizations and promote autonomous functioning.

The DTC offers services to veterans who have been determined to be seriously and persistently mentally ill and have clear evidence of substantial impairment in the ability to function in areas of (a) social role functioning/family life, (b) daily living skills/self care skills, (c) need for more intensive treatment than outpatient, (d) have primary diagnosis of psychosis, mood disorder, anxiety disorder, early stages of dementia, personality disorders. Patients should be stable enough to participate in structured group meetings and activities.

Patients become a member of the Day Treatment Center Program through referral from Primary Care Mental Health (PCMH) or inpatient psychiatry. Assessment for program appropriateness includes psychiatric evaluation by a multidisciplinary team during the first two weeks of orientation. A module plan of treatment is formulated with each individual patient, and it is updated every three months.

Core services provided include (1) individual and group therapies, (2) crisis intervention, (3) medication services, (4) community support and rehabilitation, (5) family education/support, and (5) medication administration.

Staffing

A psychiatrist, nurse and social worker form the nucleus of the DTC program. In addition to the DTC staff, a pharmacist provides bi-weekly groups, a chaplain provides weekly spiritual wellness group, a recreational therapist provides daily groups and scheduled activities, and a psychologist provides weekly group therapy.

Care Delivery

Patients are encouraged to participate in the DTC program until the resolution or stabilization of problems identified at the time of admission. Maintenance care is provided for patients needing support for independent/autonomous functioning. Dismissal from the program occurs when the patient obtains his or her treatment goals, has progressed beyond program objectives, and is not able to participate due to decrease in ability to function, exhibits behaviors that are disruptive to the general good of the program, or stops attending the program. Day Treatment Center is open four hours each weekday, with patients participating according to their identified needs and capabilities.

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HEALTH CARE FOR HOMELESS VETERANS (HCHV)

Scope of Care

Health Care For Homeless Veterans Program (HCHV) assists homeless veteran patients in achieving the maximum level of health and social functioning through reintegration into the community. Case management services include outreach programs, psychosocial assessments, counseling, referrals to VA and community resources, and assistance with housing and medical care.

Every veteran patient enrolled in HCHV has an assigned PCMH team that follows the veteran in the continuum of care. The veteran patient has access to all services offered by the medical center.

Veterans eligible for the HCHV Mental Health module are those who are: homeless, and are eligible for VA medical care benefits.

Veterans who meet the eligibility criteria and who indicate a motivation, ability, and willingness to change their living environments are accepted into the HCHV module of care.

Support Services

All Medical Center resources available as indicated by veteran eligibility pending veteran availability and staff recommendation.

QI Monitors

As identified on Mental Health Program QA Plan.

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INTENSIVE SUBSTANCE ABUSE TREATMENT (ISAT)

Scope of Care

The population served by Intensive Substance Abuse Treatment (ISAT) is the eligible veteran patient who is experiencing substance abuse problems. When appropriate, and with the patient’s consent, significant others from the patient’s family, work group, peer group and other community agencies may also participate in treatment activities. ISAT is an outpatient based treatment program. Medical and psychiatric problems that typically require inpatient hospitalization must first be stabilized before it is practical for a patient to participate in ISAT.

ISAT does not discriminate on the basis of age, race, color, national origin, gender or religious preference in offering treatment activities to the served population. ISAT is responsible to the Americans with Disabilities Act and will seek to make adequate accommodations for mentally or physically challenged individuals

Historically, the vast majority of the population served by ISAT is unemployed, homeless, lacks financial resources and is without the supportive structure of an alcohol and drug free environment. For this reason ISAT works very closely with the lodging services of Mental Health to provide food, shelter, safety and related social support services. However, when feasible, a veteran patient served by ISAT, may elect to participate from his residence in the community.

Patients are expected to maintain abstinence from alcohol and drugs, except for prescribed medications, during their participation in ISAT. Urine drug screens and breathalyzer tests are utilized to assist the patient in maintaining abstinence. While abstinence is a goal of treatment, ISAT also realizes that relapse is a symptom of the disease of substance abuse. If a patient is unable to maintain abstinence, a referral to a more suitable treatment environment will be made so that the patient may continue his care. This may include referral to other substance abuse treatment resources in Mental Health, the KCVAMC, other VA Medical Centers as well as resources in the community.

Though it is outside the immediate scope of care provided by ISAT, patients are strongly encouraged to become involved in follow-up treatment interventions that support long-term, life-style changes conducive to recovery from substance abuse. ISAT considers substance abuse to be a life-time illness and recognizes that successful participation in ISAT represents only the very beginning of treatment for the patient. For that reason, ISAT relies on multiple resources for the effective follow-up to the completion of the ISAT program. This includes the many self-help programs, follow-up substance abuse clinics available in Primary Care Mental Health and the variety of community agencies that provide services in the area of substance abuse.

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MENTAL HEALTH OUTPATIENT CLINICS

Scope of Care

Mental Health provides a variety of outpatient clinics to assure an integrated, coordinated, and comprehensive continuum of care for mental health patients by providing every patient with ready access to his/her primary mental health provider and supportive mental health services. This includes timely access to mental health services by a multidisciplinary team to provide urgent care, telephone contacts, consult services, scheduled visits, and care for walk-ins. Services include treatment, monitoring, preventive care, and education of patients and families. An individualized treatment plan is developed for each patient based on a diagnostic assessment, which is composed of a mental status examination, a psychosocial assessment, and a medical assessment appropriate to the needs of the veteran.

Staffing

The Mental Health Outpatient Clinics are staffed with a variety of clinicians to include psychiatrists, psychologists, social workers, nurses, and addiction counselors. Clinical supervision is provided by the appropriate discipline, but clinic coordination is provided by the Mental Health Clinic Manager. Health Systems Management provides clerical support.

Support Services

All available Medical Center resources are available as indicated by veteran eligibility, pending availability and staff recommendation.

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POST TRAUMATIC STRESS DISORDER CLINICAL TEAM (PCT)

Scope of Care

Post Traumatic Stress Disorder Clinical Team (PCT) provides a coordinated and comprehensive team approach for the provision of specialized assessment and treatment services to combat veterans suffering from Post Traumatic Stress Disorder (PTSD). The multidisciplinary team addresses the psychological, familial, social, spiritual, occupational, and physical needs of the patients and their families. Services include treatment, monitoring, supportive care, referrals, and education of patients and families. An individualized treatment plan is developed for each patient based on a diagnostic assessment, which is composed of psychological testing, social history assessment, psychosocial assessment, and a medical assessment appropriate to the needs of the veteran. Additionally, PCT serves as a consultative, referral, and education source for hospital and community members.

Support Services

All available Medical Center resources as indicated by veteran eligibility pending veteran availability and staff recommendation.

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OEF/OIF TREATMENT PROGRAM

Scope of Care

The OEF/OIF Treatment Program provides comprehensive services to veterans returning from Afghanistan or Iraq service. In order to provide seamless transition to veterans from active duty military and/or National Guard/Reserve, the OEF/OIF program provides a full array of medical and mental health services to returning veterans in need of assistance. It is the desire of the program to provide needed services to veterans and their families as they return from war zone duty and begin their life back in the civilian world. Services are provided based on the individual needs of the veteran and their family. Attention is paid to the systematic needs of the family unit.

Community outreach is a primary component of this service. The OEF/OIF Treatment Program is collaborating with the Department of Defense at military bases and Reserve Units to improve awareness and utilization of VA services. Veterans from any branch of service are eligible to receive needed services from the VA as they return from active duty in Afghanistan and Iraq. Community outreach also involves collaborating with community resources to serve veterans and their families. Community resources may include programs like Vet Centers, Veterans Upward Bound, Army Reserve Child and Family Services, Vietnam Veterans of America, Veterans of Foreign Wars, and Army One.

As part of the program, the VA provides primary care services and mental health services to veterans as they return and access their closest VA medical center. Mental health services are provided based on the individual needs of the veteran and their family.

Staffing

A psychiatrist, social worker, psychological technician, and program assistant form the nucleus of the OEF/OIF Treatment Program. In addition, clinical support is provided by the psychiatric program director and social work clinical team leader. Weekly individual therapy is available as well as couples therapy, family therapy and group therapy. Medical review and medication review are available as needed. Systematic clinical assessment of PTSD, depression, anxiety and anger are provided as needed to veterans entering the program using the Clinician Administered PTSD Scale, Zung Depression Scale, Beck Anxiety Scale, State-Trait Anger Expression Inventory, and the Mississippi Scale for Combat Veterans.

Care Delivery

Patients are able to utilize the OEF/OIF Program until the resolution or stabilization of problems identified at the time of admission to the program. Length of stay in the program is dependent upon the needs of the veteran and family, and attainment of treatment outcomes. Participation in the program is voluntary and program success depends greatly on patient commitment to learning new life management skills to help them deal with the current issues that brought them in to treatment. Each individual treatment plan is developed with the veteran and their family, and implemented based on their unique needs. Dismissal from the program occurs when the patient obtains his or her treatment goals, is not able to participate due to decrease in ability to function within the program, exhibits behaviors that are disruptive to the general good of the program, or stops attending the program.

Typically, the OEF/OIF Treatment Program is open to patients from 0800 to 1700 hours Monday to Friday each week, with patients participating according to their identified needs and capabilities. Times outside of this basic schedule are available as individual needs arise.

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MENTAL HEALTH LODGING - 9E

Scope of Care

The 9E Lodger Unit is a 27-bed unit utilized to offer outpatient veterans safe, temporary shelter while in transition from unstable housing situations to more therapeutic environments. Lodgers may avail themselves of the ISAT (see manual) program while in lodger status. Others may be within the Mental Health continuum, i.e. MHC – ISAT – CWT – TR or in transition to other appropriate staff designated facilities for medical, social, or behavioral assistance. Length of stay is therefore variable, with ISAT participants usually present for 17 days. The 9E Lodger Unit is part of the Mental Health Product Line and, as such, part of the medical center community, subject to hospital rules, regulations, policies, and procedures and is managed under Environment of Care standards.

Every lodged veteran is assigned to a Mental Health treatment team who follow each veteran through their participation in the specific Mental Health treatment module.
Specific services may include any of those designated by the specific Mental Health module, as well as other services within Mental Health and/or services available at the Medical Center. Special emphasis is placed on educating lodgers in self-administration of prescribed medications.

Staffing

An interdisciplinary team and unit clerk are available Mon-Fri, 8:00-5:00. Most team members have collateral assignments, usually ISAT. Evening, night, and weekend staffing by rehab technicians and addiction therapists. Unit staffed by at least one individual at all times other than Mon-Fri 8:00-5:00.

Support Staff

Social Work: Social work services are provided by social workers based on the unit. The social worker attends multidisciplinary team meetings, gathers psychosocial data and conducts family meetings. Services are available via telephone or pager.

Physician Assistants: Available on unit during administrative hours. Day to day medical needs, referrals to Primary Care, when necessary, initial medical evaluation, referral staff psychiatrist assigned when indicated, prescriptive practice as allowed by licenses, consult services.

Medical Subspecialty Care

Respiratory Therapy: Provides coverage for treatment if needed and if ordered.

Primary Care

Dental: Not routine. Referred if service connected for, or to complete service begun during some previous inpatient stay, or if in case of emergent medical need.

Clinical Support

Pharmacy: Lodger medications are kept in a locked medication room, given as per unit rules. The staff pharmacist assigned to Mental Health is available during administrative hours. Additional pharmacy service is available on demand during all other time. Pharmacy staff also facilitates Medication Information Education groups.

Dietary: Regular meals are provided unless otherwise specified by PA at time of evaluation. Dietetic consults are available for special instance (diabetes, etc.).

Prosthetics: Services by PA, primary care, or physician, if necessary.

Rehab: Services by PA, primary care, or physician if necessary.

Recreation Therapist: On unit with collateral duties. Facilitates various education groups and coordinates on/off unit recreational activities.

Pathology and Laboratory

Laboratory: Specimen analysis, usual UDS. Other tests as ordered by clinic referral or emergency

Radiology

Radiology: Outpatient service through ER, or by referral of primary care.

Information Program

Library: Unit maintains Quiet Room with books, periodicals, recovery related reading material.

Information Resource: Computer system allows rapid communication between all VAMC departments during all tours. Terminals available at 9E desk and in most staff office space.

Performance & Patient Care Improvement Program

Infection Control: The Infection Control Nurse acts as a consultant in matters related to Infection Control. She/he is available during administrative hours by phone or pager.

Patient Safety: The Patient Safety Manager acts as a consultant in matters related to patient safety. She/he is available via telephone or pager during administrative hours.

QI/UM/RM: A QARN is available during regular business hours and acts as a resource person in matters pertaining to quality improvement, utilization review, and risk management.

Customer Relations: A Patient Representative is available, by pager, to provide support and assistance to patients and employees between 7 a.m. and 5:30 p.m., Monday through Friday.

Education

Learning Resource: Reading material is available by mobile book cart. Medication information and information regarding specific issues is available in the Patient Health Education Resource Center (Learning Center).

Safety and Fire Protection: Available as needed. Unit reviewed for safety recommendations earlier, found to be in compliance.

VA Police: Security is available by telephone/radio page 24 hours per day to assist staff with volatile situations involving patients, visitors and staff.

Facilities

Environment Management: Maintains high level of cleanliness in appropriate unit areas, terminal bed cleaning, and care of staff office areas.

Engineering: Patient care areas have access to a trouble call phone for needed mechanical repairs. Additional staff may be called in during off tours as necessary. Staff members have continuous access to a computer work order system.

Business

Fiscal: Minimal need for medical supplies.

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MENTAL HEALTH INTENSIVE CASE MANAGEMENT PROGRAM
(MHICM)

Scope of Care

The MHICM program is based on a modified Assertive Community Treatment model which provides intensive community-based psychiatric and rehabilitation services to veterans with severe mental illness who are among the most frequent and long term users of VA inpatient mental health resources. The program goal is function as a multi-disciplinary team of case managers with primary care responsibility and individualized care to help veterans reduce inpatient mental health service use and cost, improve community adjustment and quality of life, and enhance satisfaction with other services.

The MHICM program provides intensive case management, including, but not limited to:

• Frequent home visits by psychologist, social workers, RNs, psychiatric technicians, and/or licensed professional counselors.
• Medication management and monitoring
• Assistance with payee, court or other legal matters
• Community placements
• Client advocacy within the VA system
• Transportation
• Assistance obtaining social services, including Social Security benefits, housing, and disabled bus passes
• Assessment and support through frequent telephone calls
• Therapy and emotional support, caregiver support
• Assistance with shopping, laundry, and activities of daily living.
• Opportunities for socialization and psychoeducation

Staffing

The MHICM program is a multi-disciplinary team which includes a psychiatrist (medical director), a psychologist (program director/case manager), a nurse (case manager), two social workers (case managers), a psychology technician (case manager), and a program support staff.

Allocated FTE 5.2 (Clinical FTE 4.0)
Target Caseload Minimum 28
Target Caseload Maximum 60

Care Delivery

Veterans are seen by a clinical MHICM staff member at least three times monthly but average about 2-3 times a week. Meetings are in person (1:1), in the community or in the MHICM office. Many veterans are seen with higher frequency, as often as 3-5 times per week if clinical need exists. Support and assessment through telephone calls is also provided as needed.

The MHICM team and program participants make an initial one-year commitment to high-intensity care. After the first year, participants are re-evaluated and can remain in the program, be shifted to a lower level of care, or be discharged as clinically indicated.

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PRE-OPERATIVE CLINIC/PRE-ADMISSION CLINIC
Surgical Care


Scope of Care

The Pre-operative Clinic provides pre-op assessment for surgical patients at the Medical Center. This clinic schedules patients for pre-op assessment within 14 days of planned surgical procedures. Appropriate lab, x-ray and tests are ordered and completed the day of clinic visit. The RN completes a pre-op assessment. Appropriate consults are initiated and completed, including but not limited to Pulmonary and Cardiology. The RN coordinates the pre-op care, assuming Anesthesiology and surgeons see the patient if needed. The RN notifies the surgeon of any problems noted during this assessment and schedules appropriate follow-up.

The RN completes pre-op teaching/instructions for the patient. The RN verifies appropriate documentation is present and complete and is responsible for taking patients records to ambulatory surgery unit or appropriate inpatient ward.

Staffing Requirements

Registered Nurse:

Current state licensure
Successful completion of annual mandatory reviews
Current BLS Health Care Provider certification
Successful completion of a designated specific competency (task(s)
Successful completion of hospital and clinic orientation programs

Staffing

Nursing Staff: A registered nurse and clerical support staff this clinic. The RN’s regular tour of duty is 7:30am – 4:00pm, Monday through Friday.

Clinical Providers: Physicians (surgeons, consulting medical specialties, and/or anesthesiologists) are available to perform pre-op H&P’s and/or consulting services based on the patient’s needs.

Clerical Support: The clerk’s regular tour of duty is Monday through Friday.

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PRIMARY CARE CLINICS

Red, Blue And Green Teams

Scope of Care

Primary Care Teams assure an integrated, coordinated, and comprehensive continuum of care for patients by providing to adult and geriatric patient with access to his/her primary provider and other supportive health services. This includes access to health services by a multidisciplinary team to provide urgent care, telephone contacts, and scheduled visits. Services include assessment, treatment, monitoring, preventive care, and education of patients and families. Clinic Services are available at the main hospital and community based outpatient clinics (CBOC).
Clinical Providers: The physicians and mid-level providers in the primary care clinics direct and provide the care of patients. This includes assessment, treatment, monitoring and preventive care as well as education on healthcare to the veterans and their family members.
Nursing Care: Nursing care focuses on the nursing process, infection control, preventive care, treatment, and patient/family education. The Nurse Manager and Assistant Nurse Manager assistant make assignments on each team giving consideration to the anticipated workload and anticipated complexity of care needs for the day. Qualifications of staff, as identified in their performance standards, are the basis for patient care assignments.

Requirements for Primary Care Staff Physician

• Board eligible internist/family practice
• Current state license
• Current DEA license
• Current BLS Health Care Provider certification
Competency of providers is ensured through the following mechanisms/processes, as appropriate:
• Credentialing and privileging of independent practitioners
• Monitoring and review of practice patterns, including proctoring of new medical staff members
• Definition of scope of practice
• Competency checks
• Regular review of proficiency
• Continuing education
Nurse Practitioner/Advance Practice Nurse
• Advanced Practice license/certification
• Current state licensure as registered nurse
• Current BLS Health Care Provider certification
• Clinical privileges in collaborative practice with a primary care physician
• Prescriptive privileges to prescribe medications
Registered Nurses
• Current State Licensure
• Current BLS Healthcare Provider Certification
• Completion of required annual mandatory training and competencies
• Phlebotomy training
• EKG training
• IV training
• CDI/PI data collection with focus on learning assessment
Licensed Practical Nurse
• Current state licensure
• BLS Health Care Provider certification
• Successful completion of Mandatory Reviews and competencies
• IV certification
• CDI/PI data collection

Health Technician

• BLS Health Care Provider certification
• Completed competency checks
• Blood pressure competency check
• EKG training
• CDI/PI data collection

Staffing/Staffing Plan

Clinical Providers: The clinics are normally staffed with a 4 - 6 physicians and mid-level provider for each clinic. When providers are unavailable, the clinics are cancelled or workload shifted for adequate coverage.
Nursing:

The staffing of the Kansas City VAMC clinics for a team of 4-6 providers includes:

• 3 RNs
• 2 Health Technicians
• 1 LPN pressure competency check
The clinic staffing may vary in accordance with the number of providers and workload requirements. A nurse manager and assistant nurse manager monitor or assess the overall care in the clinics. The clinics are established for regular day tours of 8:00 a.m. to 4:30 p.m., Monday through Friday.
Community outpatient clinics for 1-1.5 providers are staffed with 1 RN & 1 Health Technician.
Primary Care phlebotomy lab is staffed with 4-5 Health Technicians.
Clerical: The clerical staff is provided through the Health Systems Management Product Line. Clerical staff support provide a variety of services including to scheduling appointments, transcribe and entering electronic orders to include lab and x-ray, enter consults, receive patients, answer telephone calls and do the necessary work of facilitating patient transition through the clinics. The clerical staff answers questions from patients and visitors about hospital services and assist patients in solving non-medical problems related to appointments, available services and administrative issues. Clerical Support is available 7:00 am to 4:30 pm Monday - Friday
Pharmacy: Pharmacy provides two full time registered pharmacists to provide direct support within the clinic(s) to the Primary Care Providers and educational services to patients and families. There is also a full time Pharmacy Technician who works with providers to deal with patients/prescriptions for controlled substances. The technician reports directly to the Outpatient Pharmacy Supervisor. Additional pharmacy services as needed are provided by telephone and direct contact with pharmacy personnel in the Outpatient Pharmacy located next to the Primary Care clinics. Pharmacy services are available 24 hours a day. A clinical pharmacist is available to provide educational services to patients.
Dietitians: There are three registered dietitians who respond to the patient needs in the primary care clinics and inpatients. Their services can be obtained through electronic consult and telephone requests. They are available Monday through Friday, 7-4:30PM. On-call coverage is available on weekends.
Mental Health Services: Psychiatry, Psychologists, and Psychological services are available through electronic consults and telephone requests 8:00 am to 4:30 pm Monday through Friday. They provide on-call services as needed and appropriate on Off Tours.
Respiratory Therapy: Provides 24-hour service via pager for emergent problems.
Medical & Surgical Specialty Services: Consult services are available on on-call basis. These services include all surgical, medical, and nursing specialties.
Food Service: Nourishment/snacks are available to patients.

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GOLD CLINIC

Scope of Care

The Gold Clinic specializes in the delivery of comprehensive medical and surgical care to the adult and geriatric veteran patient. These clinics provide specialty services to include: General Surgery and ET Ostomy, Neurosurgery, Plastic Surgery, Vascular Surgery, Orthopedics, Urology, Ophthalmology, Genito-urinary Surgery, GYN, Otolaryngology, Oral Surgery, and Anesthesiology.

Staffing Requirements

Physician

• Board eligible in specialty field
• Current state licensure . Current DEA license
• Current BLS Health Care Provider card

Competency of providers is ensured through the following mechanisms/processes, as appropriate:

• Credentialing and privileging of independent practitioners
• Monitoring and review of practice patterns, including proctoring of new medical staff members
• Definition of scope of practice
• Competency checks
• Regular review of proficiency
• Continuing education

RN/LPN

• Current state licensure
• Current BLS Health Care Provider card
• Annual mandatory reviews
• Knowledge of and ability to perform various clinical duties
o Dressing changes
o Suture and staple removal
o Cast and splint application and removal
HT / NA

• Training in phlebotomy
• Training in ECG recording
• Current BLS Health Care Provider card
• Annual mandatory reviews
• Completion of clinic-specific competencies

Clinical Responsibilities

Assignments are carried out by all clinic nursing personnel except where noted "RN and/or LPN's only".

• Organize clinic with availability of clinic list and equipment
• Check patients into clinic. Obtain vital signs and assessments and enter in CPRS, check availability of x-rays
• Wound care, dressing changes, suture and staple removal, and steri-strip application
• Perform self-catheterization training, straight catheterization, prime and pulls, and bladder scans
• Assist providers with any and all procedures as needed
• Prep patients for biopsies
• Set up sterile fields
• Administer PO and 1M medications (RN & LPN's only)
• Order labs in computer
• Follow up with nursing home patients, arrange travel, meals, and meds
• Order medications and supplies for clinic area
• Document patient encounters in CPRS
• Train patient for all aspects of their care

Staffing

Clinical Providers: The physicians in the clinics direct and provide care to our patients. This includes treatment, monitoring and preventive care as well as education on health care to the veterans and their family members.

Nursing: 1 RN / 3 LPN's / 2 HT's

Clerical Support: Clerical support is provided by four (4) patient service assistants during clinic hours.

Pharmacy: Pharmacy services are available 24 hours a day. A clinical pharmacist is available to provide educational services to patients.

Food Service: Nourishment/snacks are available to patients.

Consulting Services: Provides support and consulting services in the areas of ER services, administrative medicine, psychosocial support for the continuum of care, community liaison, spiritual health care, dental services, optometry services, and audiology services.

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SILVER CLINIC

Scope of Care

The Silver Clinic specializes in the delivery of comprehensive medical and surgical care to adult and geriatric patients. These clinics provide specialty services to include: Cardiovascular, Endocrine, Gastroenterology, Hematology, Oncology, Nephrology, Infectious Disease, Neurology, Diabetes, Pulmonary Medicine, Dermatology, HTN, Rheumatology, and Immunology.

Staffing Requirements

Physician

• Board eligible in specialty field
• Current state licensure
• Current DEA license
• Current BLS Health Care Provider card

Competency of providers is ensured through the following mechanisms/processes, as appropriate:

• Credentialing and privileging of independent practitioners
• Monitoring and review of practice patterns, including proctoring of new medical staff members
• Definition of scope of practice
• Competency checks
• Regular review of proficiency
• Continuing education

RN/LPN

• Current state licensure
• Current BLS Health Care Provider card
• Annual mandatory reviews
• Completion of clinic-specific competencies

HT / NA

• Training in phlebotomy
• Training in ECG recording
• Current BLS Health Care Provider certification
• Annual mandatory reviews
• Completion of clinic-specific competencies

Clinical Responsibilities

Assignments are carried out by all clinic nursing personnel except where noted "RN and/or LPN's only".

• Organize clinic with availability of clinic list and equipment
• Check patients into clinic. Obtain vital signs and assessments and enter in CPRS, check availability of x-rays
• Wound care, dressing changes, suture and staple removal, and steri-strip application
• Perform self-catheterization training & straight catheterization
• Assist providers with any and all procedures as needed
• Prep patients for biopsies
• Set up sterile fields
• Administer PO and 1M medications (LPN only)
• Order labs in computer
• Follow up with nursing home patients, arrange travel, meals, and meds
• Order medications and supplies for clinic area
• File patient encounters
• Train patient for all aspects of their care

Staffing

Clinical Providers: The physicians in the clinics direct and provide the care to our patients. This includes treatment, monitoring and preventive care as well as education on healthcare to the veterans and their family members.

Nursing: 4 LPN / 1 HT / 2 RNs (Diabetes)

Clerical Support: Four (4) patient services assistants provide Clerical support during clinic hours.

Pharmacy: Pharmacy services are available 24 hours a day. A clinical pharmacist is available to provide educational services to patients.

Food Service: Nourishment/snacks are available to patients. Meals are available with the use of meal tickets if needed (Onc/Chemo only).

Consulting Services: Provides support and consulting services in the areas of ER services, administrative medicine, psycho-social support for the continuum of care, community liaison, spiritual health care, dental services, optometry services, and audiology services.

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COMMUNITY BASED OUTPATIENT CENTERS

(CBOCs)


Scope of Care

The Community Based Outpatient Centers (CBOCs) affiliated with the Kansas City Veterans Affairs Medical Center are committed to improving the health of the served veteran population by providing limited primary care and coordinating services from the medical center for veterans needs related to mental health care, specialty care, and related social support services. Service is limited in that the CBOCS do not provide emergency care and have no ancillary support services or immediate diagnostic testing capability on site.

The CBOCs are currently located in:

• Belton, Missouri
• Cameron, Missouri in association with the Missouri State Veterans Nursing Home at Cameron
• Nevada, Missouri
• Warrensburg, Missouri in association with the Missouri State Veterans Nursing Home at Warrensburg
• Paola, Kansas

Clinic Hours are 8:00 am to 12:00pm and 1:00 pm to 4:00 pm Monday through Friday. Each clinic closes from 1:00 pm to 4:00 pm one day each week for administrative duties

Staffing/Staffing Requirement

Registered Nurses

• Current State Licensure
• Current BLS Healthcare Provider Certification
• Completion of required annual mandatory training and competencies
• Phlebotomy Training
• EKG Training
• IV Training
• CDI/PI data collection with focus on Learning Assessment

Health Technician (1 per CBOC, currently recruiting for the Belton and Paola CBOCS)

• BLS Health Care Provider certification
• Completed competency checks
• Blood pressure competency check
• Phlebotomy Training
• EKG Training
• CDI/PI data collection

Clerical: Patient Services Assistant (1 per CBOC)

• Check patients in to clinic
• File patient encounters
• Enroll Patients into VA System
• Enter physician orders
• Enter Consults
• Answers telephone
• Makes/reschedules/cancels appointments

Clinical Provider: The physician or Nurse Practitioner in each center directs and provides the care to our patients. This includes treatment, monitoring, and preventive care as well as education on healthcare to veterans and their family members.

Pharmacy: Pharmacy Services are available during the workday via computer access. A clinical pharmacist is also available by telephone during these hours to assist the provider or provide educational material to the patient.

Food Service: Nourishment/Snacks are available for diabetic patients

Other Support Services/Functions:

Support for ancillary services is provided through electronic requests and consultations for laboratory, radiological, and specialty care services.

Clinical Support

Prosthetics: Available during the working day via computer consult.

Rehab Services: Can be ordered through the consult package via computer. In most cases patients will travel to KCVAMC to receive the necessary services.

Radiology

Telephone and/or computer requests maybe submitted during the working day. Patients must travel to Kansas City for routine radiological exams and specialty tests. In the event of the need for an urgent need for an exam they can be scheduled at a local healthcare facility at the request of the clinic provider using fee-basis services

Pathology & Laboratory

Blood for routine tests is drawn and processed on site and then transported to the hospital via courier. Results are available to the provider for most tests the next morning via computer. In the case of tests that need to be done to make an immediate diagnosis the provider can send the patient to the local healthcare facility utilizing fee-basis services.

Mental Health Services

Psychiatry services are available through the consult package and by telephone as required.

Business/Fiscal

Available by phone or computer

Facilities/Supplies

Basic cleaning and maintenance needs are covered in the local contract for each CBOC.

Performance & Patient Care Improvement

Infection Control: The Infection Control Nurse acts as a consultant in matters related to Infection Control. She/he is available during administrative hours by phone or pager.

Patient Safety: The Patient Safety Manager acts as a consultant in matters related to patient safety. She/he is available via telephone or pager during administrative hours.

QI/UM/RM: A QARN is available during regular business hours and acts as a resource person in matters pertaining to quality improvement, utilization review, and risk management.

Customer Relations: A Patient Representative is available, by pager, to provide support and assistance to patients and employees between 7 a.m. and 5:30 p.m., Monday through Friday.

Education

Learning Resource: Reading material is available by mobile book cart. Medication information and information regarding specific issues is available in the Patient Health Education Resource Center.

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