Comprehensive Healthcare Inspection of the VA Loma Linda Healthcare System in California

Submitting OIG:

Report Description:

This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the VA Loma Linda Healthcare System, which includes the Jerry L. Pettis Memorial Veterans’ Hospital and multiple outpatient clinics in California. This evaluation focused on five key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care • Mental health (emergency department and urgent care center suicide prevention initiatives) The OIG issued five recommendations for improvement in three areas: 1. Leadership and organizational risks • Sentinel events and institutional disclosures 2. Quality, safety, and value • Adverse events 3. Medical staff privileging • Focused Professional Practice Evaluation processes • Reprivileging reviews

Date Issued:

Wednesday, May 24, 2023

Agency Reviewed / Investigated:

Department of Veterans Affairs

Submitting OIG-Specific Report Number:

22-00048-120

Component, if applicable:

Veterans Health Administration

Location(s):

Loma Linda, CA

United States

Blythe, CA

United States

Corona, CA

United States

Redlands, CA

United States

Murrieta, CA

United States

Palm Desert, CA

United States

Rancho Cucamonga, CA

United States

Victorville, CA

United States

Type of Report:

Review

Questioned Costs:

Funds for Better Use:

Number of Recommendations:

View Document:

Attachment	Size
VAOIG-22-00048-120.pdf	3.74 MB

Additional Details Link:

https://www.va.gov/oig/publications/report-summary.asp?id=5283

Recommendation Number	Recommendation Status	Significant Recommendation
01	Open	No
The Director evaluates and determines reasons for noncompliance and ensures leaders evaluate sentinel events and conduct institutional disclosures when criteria are met.
02	Open	No
The Director evaluates and determines any additional reasons for noncompliance and ensures that for all events assigned an actual or potential safety assessment code score of three, staff either complete an individual root cause analysis or include the event in an aggregated patient safety review.
03	Open	No
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers use Focused Professional Practice Evaluation criteria that are defined in advance and accepted by the practitioner.
04	Open	No
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain clinical managers define time frames for Focused Professional Practice Evaluations.
05	Open	No
The Chief of Staff evaluates and determines any additional reasons for noncompliance and verifies that the Medical Executive Council’s meeting minutes consistently reflect the data reviewed for licensed independent practitioners’ re-privileging requests and the rationale for the recommendations.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

Open

The Director evaluates and determines reasons for noncompliance and ensures leaders evaluate sentinel events and conduct institutional disclosures when criteria are met.

Open

The Director evaluates and determines any additional reasons for noncompliance and ensures that for all events assigned an actual or potential safety assessment code score of three, staff either complete an individual root cause analysis or include the event in an aggregated patient safety review.

Open

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers use Focused Professional Practice Evaluation criteria that are defined in advance and accepted by the practitioner.

Open

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain clinical managers define time frames for Focused Professional Practice Evaluations.