Comprehensive Healthcare Inspection of the Edward Hines, Jr. VA Hospital, Hines, Illinois

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the Edward Hines Jr. VA Hospital. The inspection covers leadership and organizational risks and key processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility’s leadership team appeared relatively stable. Employees appeared generally satisfied, but opportunities seemed to exist for employees to feel encouraged to do the right thing. Outpatient satisfaction scores were above VHA averages, while inpatient satisfaction could be improved. The OIG noted organizational risk factors, if uncorrected, can perpetuate noncompliance with requirements and/or lapses in patient safety. The leadership team was generally knowledgeable, within their scope of responsibility, about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to improve care and performance of metrics that are likely contributing to the current SAIL “3-star” and CLC “1-star” quality ratings. The OIG issued 10 recommendations for improvement in the following areas: (1) Quality, Safety, and Value • Interdisciplinary utilization management data review • Resuscitation episode reviews (2) Medical Staff Privileging • Ongoing professional practice evaluations (3) Environment of Care • Fire safety • Infection prevention (4) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (5) Geriatric Care: Antidepressant Use among the Elderly • Patient/caregiver education and understanding of education on medications • Medication reconciliation (6) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee core membership • Cervical cancer screening data tracking