Healthcare Inspection — Alleged Mismanagement of Gastroenterology Services and Quality of Care Deficiencies, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois

OIG conducted an inspection in response to allegations of mismanagement of gastroenterology (GI) services and other quality of care deficiencies at the Captain James A. Lovell Federal Health Care Center (facility), North Chicago, IL. We received multiple allegations of “turmoil and chaos” related to a recent reorganization of senior leadership. We focused on prioritization of GI services, alleged quality of care deficiencies, requests for unnecessary GI procedures, and the lack of coordination of non-VA GI care. We substantiated allegations that facility gastroenterologists had been directed by facility leaders to prioritize care in favor of active duty service members and that scheduled GI procedures were limited to four per day. However, we found that the facility leaders’ decision to prioritize care in favor of service members was made in accordance with a 2010 Department of Defense/VA Executive Agreement that outlines terms of operation for the facility and that veterans were receiving care when necessary through the Non-VA Medical Care Program. We substantiated a significant lapse in the management of a patient’s low blood sugar. However, we found the facility had appropriately addressed the issue. We did not substantiate the allegations that an increase in falls, pressure ulcers, urinary tract infections, elopements, diversions, and wrong site procedures occurred as a result of senior leaders’ mismanagement after a reorganization in spring 2014 or that facility leaders requested that GI staff perform unnecessary procedures. We also did not substantiate that the facility lacked a process for coordinating non-VA GI care. However, we did find inconsistencies in the posting of non-VA GI procedure results into the VA electronic health record. We recommended that the Facility Director ensure that documentation of procedure results from non-VA GI care providers is obtained and available in the electronic health record for review in a timely and consistent manner.