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Quality of Service at LVMC

Community Forum

Tuesday, June 20, 2017, from 6:00pm to 7:30pm

LVMC Chief Executive Officer Jim Raggio will discuss and answer questions about recent surveys conducted at the hospital, including the successful Center for Improvement in Healthcare Quality (CIHQ) Triennial inspection, a state Department of Public Health validation survey that resulted in a determination of non-compliance and a state licensing division follow-up validation survey that found LVMC in substantial compliance.

The Community Forum will take place at Lompoc Valley Medical Center: Hospital in the Ocean's Seven Cafe. All interested members of the Lompoc community are welcome to attend. 

Statement from our Board of Directors

Lompoc Valley Medical Center (LVMC) has provided quality medical care to the residents of this community for 71 years. In recent weeks, there has been much attention on the accreditation surveys conducted at the hospital in the past 14 months, including a state Department of Public Health validation survey completed in February, with a resolution of substantial compliance on June 7. To allay any lingering concerns, we say to you emphatically: Lompoc Valley Medical Center and its entire medical and professional staff provide safe and quality care for our community.

We, the Board of Directors, want to assure our community that LVMC meets or exceeds nationally accepted standards of quality patient care and we commend the work of our more than 700 employees. Chief Executive Officer Richard Curtis of the Center for Improvement in Healthcare Quality – the Medicare-approved accrediting organization for LVMC – said in a letter June 11, 2017, to LVMC:

“Our survey of LVMC was thorough, rigorous, but fair. Our survey did not identify serious issues related to the safety and quality of care provided by LVMC to its community.”

We stand by that statement and our hospital.

The Board of Directors of LVMC

  • Ray Down, Board President
  • David L. McAninch, III, MD
  • Mary Sharp
  • Roger McConnell
  • Linual A. White, Jr.
  • Michael Gill, MD, Chief of Staff

Statement from our CEO

As Chief Executive Officer of Lompoc Valley Medical Center, I want to address the recent survey process our hospital experienced.

I am so confident in our preparation that we look forward to each and every unannounced survey. No one here would argue with the benefit of having a fresh set of eyes looking at our operation.

We are also proud of our culture, which is laser-focused on opportunities to improve the wonderful care we provide. We have found that most surveys result in minor adjustments to policies and procedures that are easily implemented and ultimately positively impact our services.

All surveys are unannounced, which requires hospitals to maintain vigilance towards shifting federal and state standards. To understand how often this occurs, during the past 14 months LVMC has been subjected to eight unannounced surveys. In these surveys, hospitals are deemed either “not in compliance,” or “in substantial compliance.”

LVMC’s surveys in the past year were:

  1. Vaccines for Children Inspection - April 2016 (LVMC in Substantial Compliance)
  2. CDPH Licensing Division Inspection - Aug 2016 (LVMC in Substantial Compliance)
  3. Board of Pharmacy Inspection - Oct 2016 LVMC in Substantial Compliance)
  4. Center for Improvement in Healthcare Quality (CIHQ) Triennial CMS (Centers for Medicare & Medicaid Services) Inspection - Jan 2017 (LVMC in Substantial Compliance)
  5. CDPH Licensing Division - CMS Validation Survey Feb 2017 (LVMC found NOT in Substantial Compliance)
  6. CA Medical Waste Inspection - May 2017 (LVMC in Substantial Compliance)
  7. Board of Pharmacy Inspection - May 2017 (LVMC in Substantial Compliance)
  8. CDPH Licensing Division - Follow-up CMS Validation Survey (LVMC in Substantial Compliance)

You might question how the CMS Validation Survey performed in February could result in such divergent results than all the others in the past year. One explanation is that the survey team believed any deviation from a current policy or procedure was a non-compliant issue.

For example, the February surveyors reviewed 33 charts for pain assessments and found 100 percent of the patients had a pain assessment documented. Unfortunately, we received a citation because one chart had a pain assessment documented 61 minutes after a medication was given and our policy stated that it needed to be completed within 60 minutes. Another example involves nursing assessments. Again, 33 charts were reviewed and 100 percent had a nursing assessment performed, but 1 assessment was not documented in the timeframe outlined in our policy.

The survey team found LVMC in 97 percent compliance with pain and nursing assessments, yet we received 2 citations. The Centers for Medicare and Medicaid Services standards require a hospital to be in “substantial compliance” to pass a survey. Our rate of 97 percent chart accuracy is fantastic -- and has always been considered substantial compliance.

Every hospital inspection results in findings of some level and the majority of the CDPH citations at LVMC were technical in nature and easily resolved by modifying our current policy or procedures.

LVMC’s Plan of Correction was submitted to the state on May 5 and all CMS recommendations were implemented on that date.

LVMC is confident of its ability to care for our community and is proud to have been found in substantial compliance by CMS on June 7.

In a letter dated June 11, 2017, Chief Executive Officer Richard Curtis of the Center for Improvement in Healthcare Quality – the Medicare-approved accrediting organization for LVMC – said the hospital “meets or exceeds nationally accepted standards for the provision of safe, quality patient care.”

 

Read the Letter

From Chief Executive Officer Richard Curtis
of the Center for Improvement in Healthcare Quality
regarding Lompoc Valley Medical Center's CPHD Survey.

Download the Full Letter

 

Thank you for trusting Lompoc Valley Medical Center with your healthcare needs.

Jim Raggio, CEO

 

Remote Access

All users who wish to access Lompoc Valley Medical Center (LVMC) hosted patient health information while offsite may make use of our LVMC Connect or our LVMC "Clinician Portal" depending on need and access level.

Access will be granted once all of the forms (available below) are filled-out, signed, and returned by the appropriate parties. 

Fill out these forms:

Return your completed forms To:

Information Systems
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Fax: (805) 737-5770
Phone: (805) 737-5751

If an account remains inactive for more than 90 days, it will be deactivated. In order to restore access, the user must contact the Information Systems department to request re-activation.

Contact Us

We are dedicated to assuring you have a positive experience and want to hear from you. We will make every effort to reply to your emails as soon as possible.

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Email Us

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We request that you do not email medical information as our email addresses are not to be used for medical advice. Please contact your provider directly if you have questions about your current treatment.  If you are experiencing a medical emergency, call 911.

Our Locations

Lompoc Valley Medical Center:
Hospital

1515 E Ocean AVE
Lompoc, CA 93436
(805) 737-3300

Lompoc Valley Medical Center:
Comprehensive Care Center

216 N Third ST
Lompoc, CA 93436
(805) 736-3466

Champion Center

303 S C ST
Lompoc, CA 93436
(805) 875-8800 

Lompoc Valley Medical Center:
Family Caregiver Support Network

223 S C ST
Lompoc, CA 93436
(805) 875-8875

Lompoc Valley Medical Center: 
Hematology-Oncology

1213 E Ocean AVE, #102
Lompoc, CA 93436
(805) 735-1155

Lompoc Valley Medical Center:
Laboratory & Imaging

1111 E Ocean AVE, #2
Lompoc, CA 93436
(805) 735-3608

Lompoc Valley Medical Center:
Physician Services

136 N Third ST
Lompoc, CA 93436
(805) 736-1253

Lompoc Valley Medical Center:
Surgical Service

1515 E Ocean AVE
Lompoc, CA 93436
(805) 737-3365

Lompoc Valley Medical Center:
Sleep Disorder Center

228 S D ST
Lompoc, CA 93436
(866) 218-8350


For Healthcare Professionals

Remote Access

All users who wish to access Lompoc Valley Medical Center (LVMC) hosted patient health information while offsite may make use of our LVMC Connect or our LVMC "Clinician Portal" depending on need and access level.

Access will be granted once all of the forms (available below) are filled-out, signed, and returned by the appropriate parties. 

Fill out these forms:

Return your completed forms To:

Information Systems
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Fax: (805) 737-5770
Phone: (805) 737-5751

If an account remains inactive for more than 90 days, it will be deactivated. In order to restore access, the user must contact the Information Systems department to request re-activation.

Find Which Radiology Exam to Order

LVMC's Diagnostic Imaging department has created the following guide to help staff order the appropriate exam.

Instructions on How to Filter by Symptoms/Concerns:

  1. Open to the spreadsheet and the bottom called "Exam to Order".  
  2. Go on the tabs along the bottom.
  3. Click on which modality you want to use (MRI, CT, Ultrasound & Mammogram, or All).

  Exam to Order.xlsx

ICD-10 Resources

CA Breast Density Law

California Governor Jerry Brown signed into law SB1538 requiring health facilities performing mammography examinations, such as Lompoc Valley Medical Center, that identify patients having heterogeneously dense breasts or extremely dense breasts, based on the Breast Imaging Reporting and Data System established by the American College of Radiology, to include such existence of heterogeneously dense breasts in the summary of the written report that is sent to the patient.

The State of California Legislature has recently passed but not funded a law mandating that radiologists must report to the patient her breast density in the patient lay letter and that increased density could increase the patients risk for breast Cancer. To find out more click the link below:

Santa Barbara Breast Care Alliance Letter about Breast Density.

Medical Staff Services

For all medical staff activities including credentialing applicants for initial and reappointment; distributing information regarding membership and privileges to appropriate departments; preparing committee agendas and packets; and recording meeting minutes.

Office hours: 8:00 AM to 4:30 PM, Monday through Friday.
Director of Medical Staff Services: (805) 737-3303
Director of Medical Affairs: (805) 875-8902
Fax: (805) 737-3326

Bylaws, Rules & Regulations Word Versions