Healthcare Inspection - Review of Quality of Care, Management, and Operations, Iowa City VA Health Care System, Iowa City, Iowa

OIG conducted a comprehensive review of the Iowa City VA Health Care System in response to a request from Senator Charles E. Grassley. OIG assessed the merit of allegations about quality of care and that concerns expressed by staff which “have been largely ignored.” We found that high quality medical care has been maintained. However, a pervasive lack of support for staff problem-solving is a potential threat to patient safety, and that several process deficiencies were identified. During a prolonged period when key leadership positions were held by individuals on a temporary basis, decisions were delayed or never made, and a highly competent professional staff was frustrated by the persistent ineffectiveness of senior leadership. We recommended that the Veterans Integrated Service Network Director ensure that system leaders take appropriate action in response to identified problems and communicate action plans to staff. We also recommended that system leaders clarify organizational lines of authority and responsibility and improve components of Environment of Care and Pharmacy management.