Comprehensive Healthcare Inspection of the Jesse Brown VA Medical Center, Chicago, Illinois

Report Information

Issue Date
Report Number
18-04673-138
VISN
State
Illinois
Indiana
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
11
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
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

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures utilization management reviewers complete at least 75 percent of all inpatient stay reviews and monitors the reviewers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the Cardiopulmonary Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and monitors the Cardiopulmonary Resuscitation Committee’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that clinical managers initiate focused professional practice evaluations that include clearly delineated timeframes and monitors clinical managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that controlled substances program staff perform one random day’s reconciliation of controlled substances returned to pharmacy from every automated dispensing unit during monthly inspections and monitors the program staff’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the controlled substances inspectors verify documentation for two signatures for any waste of partial doses and monitors controlled substances inspectors’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that mental health and primary care providers complete military sexual trauma mandatory training requirements no later than 90 days after entering their position and monitors providers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures clinicians provide and document patient/caregiver education and monitors clinicians’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that program managers implement a process for trackingcervical cancer screening data and monitors program managers’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that providers notify patients of abnormal cervical pathology results within the required timeframe and monitors providers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the urgent care center is discontinued and patient needs and flow are more adequately addressed in the established emergency department and primary care clinic, and monitors compliance.