Comprehensive Healthcare Inspection of the Marion VA Medical Center in Illinois

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Marion VA Medical Center and outpatient clinics in Illinois, Indiana, and Kentucky. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on 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 executive leadership team had been working together for 17 months. Patient experience surveys indicated that patients appeared satisfied with their care. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial risk factors. The leadership team, specifically the Chief of Staff and Associate Director for Patient Care Services, had opportunities to improve their knowledge within their scopes of responsibility about Strategic Analytics for Improvement and Learning data and should continue to take actions to sustain and improve performance. The OIG issued 29 recommendations for improvement in eight areas: (1) Quality, Safety, and Value • Quality management activities • Utilization management processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit review forms (3) Environment of Care • Infection prevention procedures • Health information protection (4) Medication Management • Pain screening • Risk assessment • Urine drug testing • Informed consent • Patient follow-up • Pain Management Committee activities (5) Mental Health • Safety plans • Staff training (6) Care Coordination • Treatment notes (7) Women’s Health • Required staffing • Access to care and emergency contraceptives • Women Veterans Health Committee membership (8) High-Risk Processes • Required administrative processes • Staff training