Federal Reports

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

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

DHS does not have sufficient policies and procedures to address employee misconduct. Specifically, the Department’s policy does not include procedures for reporting allegations of misconduct, clear and specific supervisor roles and expectations, or clearly defined key discipline terms. These deficiencies occurred because DHS’ Employee Relations office has limited staff, who do not believe they are responsible for managing the allegation process. DHS also does not effectively manage the misconduct program throughout the Department, lacking data monitoring and metrics to gauge program performance. Without oversight through defined policies and program management, DHS cannot make informed decisions to improve the program and ensure all components manage the misconduct process consistently. Additionally, this shortcoming could lead to costly litigation due to inappropriate or unenforceable disciplinary determinations.