Comprehensive Healthcare Inspection of the Edward Hines, Jr. VA Hospital, Hines, Illinois

Report Information

Issue Date
Report Number
18-04676-142
VISN
State
Illinois
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
10
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the Edward Hines Jr. VA Hospital. The inspection covers leadership and organizational risks and key processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma 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 Operations. The facility’s leadership team appeared relatively stable. Employees appeared generally satisfied, but opportunities seemed to exist for employees to feel encouraged to do the right thing. Outpatient satisfaction scores were above VHA averages, while inpatient satisfaction could be improved. The OIG noted organizational risk factors, if uncorrected, can perpetuate noncompliance with requirements and/or lapses in patient safety. The leadership team was generally knowledgeable, within their scope of responsibility, about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to improve care and performance of metrics that are likely contributing to the current SAIL “3-star” and CLC “1-star” quality ratings. The OIG issued 10 recommendations for improvement in the following areas: (1) Quality, Safety, and Value • Interdisciplinary utilization management data review • Resuscitation episode reviews (2) Medical Staff Privileging • Ongoing professional practice evaluations (3) Environment of Care • Fire safety • Infection prevention (4) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (5) Geriatric Care: Antidepressant Use among the Elderly • Patient/caregiver education and understanding of education on medications • Medication reconciliation (6) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee core membership • Cervical cancer screening data tracking

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 facility director ensures the interdisciplinary group or committee that reviews utilization management data includes a representative from the chief Business Office revenue-utilization review and monitors the committee’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the Acute and Critical Care Committee conducts a complete analysis of resuscitation episodes by reviewing required elements and monitors the committee’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that the Medicine Service Line chief includes required gastroenterology-specific criteria in ongoing professional practice evaluations of gastroenterology practitioners and monitors the Medicine Service Line chief’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director confirms storage rooms meet fire safety requirements by maintaining the required amount of open space between fire sprinkler deflectors and the top of stored items and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director ensures that managers store clean and dirty medical equipment separately and monitors managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that providers complete military sexual trauma mandatory training within the required timeframe and monitors providers’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that clinicians provide and document patient/caregiver education and assess understanding of education provided about newly prescribed medications and monitors clinicians’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain clinicians review and reconcile medications and monitors clinicians’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the Women Veterans Health Committee includes required core members, designated members consistently attend meetings, and monitors the committee’s compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that program managers implement a process for tracking results notification and follow-up care data for abnormal cervical cancer screenings and monitors program managers’ compliance.