Comprehensive Healthcare Inspection Program Review of the Iowa City VA Health Care System, Iowa

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Iowa City VA Health Care System. The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health: Posttraumatic Stress Disorder Care; Long-term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-up; and High-risk Processes: Central Line-associated Bloodstream Infections. The Facility had generally stable executive leadership since September 2017 and active engagement with employees and patients as evidenced by satisfaction scores. The OIG reviewed accreditation agency findings, sentinel events, disclosure of adverse patient events, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results and did not identify any significant organizational risk factors. Although the leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to improve care and maintain performance of selected Quality of Care and Efficiency metrics that are likely contributing to the improvement from the previous “2-Star” rating to the current “3-Star” rating. The OIG noted findings in three of the clinical operations reviewed and issued three recommendations that are attributable to the Director and Chief of Staff. The identified areas with deficiencies are: (1) Credentialing and Privileging • Ongoing Professional Practice Evaluation process (2) Medication Management: Controlled Substances Inspection Program • Reconciliation of controlled substance returns to pharmacy stock (3) Long-term Care: Geriatric Evaluations • Program oversight and evaluation