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

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Jesse Brown VA Medical Center and multiple outpatient clinics in Illinois and Indiana. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The medical center’s executive leadership team had one vacancy in its five key positions. The Medical Center Director had served in an acting capacity for two weeks, and the chief of staff position had been filled for three months. Survey results indicated opportunities to improve employee satisfaction. Patient survey results indicated overall satisfaction. The OIG did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about Strategic Analytics for Improvement and Learning measures and actions taken during the previous 12 months to maintain or improve performance. The OIG issued 22 recommendations for improvement in seven areas: (1) Quality, Safety, and Value • Utilization management processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit reviews • State licensing board reporting (3) Medication Management • Behavior risk assessments • Concurrent medication therapy • Urine drug testing • Informed consent • Patient follow-up • Pain Committee (4) Mental Health • Patient follow-up • Suicide safety plans • Suicide prevention training (5) Care Coordination • Multidisciplinary committee (6) Women’s Health • Women’s health primary care providers • Women Veterans Health Committee (7) High-Risk Processes • Standard operating procedures • Annual risk analysis • Competency assessments