Comprehensive Healthcare Inspection of the Jesse Brown VA Medical Center, Chicago, Illinois

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Jesse Brown VA Medical Center. The inspection covers leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. For this inspection, the OIG focused on Quality, Safety, and Value (QSV); Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma (MST) 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 (UCC) Operations. The OIG noted a relatively stable leadership team but saw opportunities for improvement of inpatient and specialty care outpatient experiences. Organizational risks detailed in this report, if uncorrected, can perpetuate noncompliance with requirements and/or lapses in quality care. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “3-star” and CLC “4-star” quality ratings. The OIG issued 11 recommendations for improvement in the following areas: (1) QSV • Completion of required inpatient stay reviews • Interdisciplinary review of utilization management data • Review of resuscitation episodes (2) Medical Staff Privileging • Focused professional practice evaluation process (3) Medication Management • Reconciliation of controlled substances returned to pharmacy • Verification of signatures for controlled substances waste (4) Mental Health: MST Follow-up and Staff Training • Completion of provider training (5) Geriatric Care: Antidepressant Use • Patient/caregiver education on medications (6) Women’s Health: Abnormal Cervical Pathology Results • Process for tracking cervical cancer screening data • Patient notification of abnormal results (7) High-risk Processes: Emergency Department and UCC Operations • Emergency Department and Primary Care Clinic adequately address patient needs and flow