Report Summary

Title: Comprehensive Healthcare Inspection of the VA Illiana Health Care System in Danville, Illinois
Report Number: 20-00062-205 Download
Issue Date: 7/29/2020
City/State: Danville, IL
Peoria, IL
Decatur, IL
Springfield, IL
Mattoon, IL
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Illiana Health Care System and multiple outpatient clinics in Illinois. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment.

The executive leadership team positions were filled more than six months prior to the on-site visit. Survey results revealed opportunities for the Associate Director to improve employee satisfaction and for the Chief of Staff and Associate Director Patient Care Services to improve staff feelings of “moral distress” at work. Patient experience survey data indicated that patients appeared satisfied with their care. The OIG’s review of the system’s accreditation findings did not identify any substantial organizational risk factors. Executive leaders were knowledgeable within their scopes of responsibilities about selected Strategic Analytics for Improvement and Learning data and should continue to take action to sustain and improve performance.

The OIG issued 13 recommendations for improvement in five areas:

(1) Medical Staff Privileging

• Ongoing professional practice evaluations

• Provider exit reviews

(2) Medication Management

• Aberrant behavior risk assessment

• Concurrent medication therapy

• Urine drug testing

• Informed consent

(3) Mental Health

• Patient follow-up

• Staff training

(4) Women’s Health

• Designated providers

• Women’s Veterans Health Committee

(5) High-Risk Processes

• Standard operating procedures

• Annual risk analysis

• Staff competencies