Comprehensive Healthcare Inspection Program Review of the Marion VA Medical Center, 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 Marion VA Medical Center. 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. Apart from the Director, the Facility had a relatively new leadership team. The OIG noted that Facility leaders were actively taking measures to improve employee engagement and satisfaction scores and seemed committed to creating and sustaining positive change. Patients were generally satisfied with the leadership and care provided, and Facility leaders appeared to be actively engaged with improvement activities to enhance patient experiences. The OIG reviewed accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results and did not identify any substantial organizational risk factors. The leadership team should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics that are likely contributing to the current “2-Star” rating. The OIG noted findings in four of the clinical operations reviewed and issued six recommendations that are attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Ongoing Professional Practice Evaluation process (2) Environment of Care • Panic alarm testing and follow-up • Annual Emergency Operations Plan review (3) Controlled Substances Inspection Program • Annual physical security survey • Verification of drugs held for destruction (4) Central Line-associated Bloodstream Infections • Staff education