Comprehensive Healthcare Inspection Program Review of the Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois

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 Captain James A. Lovell Federal Health Care Center (Facility). 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 Care: 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 is the only fully integrated VA-DoD medical Facility in the United States addressing the needs and expectations of active duty military, military families, and the local veteran population. The OIG noted that Facility leadership, uniquely shared between VHA and DoD, was actively engaged with employees to improve satisfaction scores. Organizational leadership supported patient safety, quality care, and other positive outcomes. The OIG identified organizational risks related to a lack of consistent risk management, quality management, and/or patient safety processes, including those associated with institutional disclosures, root cause analyses, and peer review activities that may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented. The OIG noted findings in four of the eight areas of clinical operations reviewed and issued five recommendations that are attributable to the Director, Chief Medical Executive, and Associate Director for Facility Support. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Physician Utilization Management Advisors’ documentation of decisions • Interdisciplinary review of utilization management data (2) Credentialing and Privileging • Focused Professional Practice Evaluation process (3) Environment of Care • Environmental cleanliness and maintenance (4) Medication Management: Controlled Substances Inspection Program • Annual physical security actions