Report Summary

Title: Comprehensive Healthcare Inspection of Veterans Integrated Service Network 12: VA Great Lakes Health Care System in Westchester, Illinois
Report Number: 20-00058-250 Download
Issue Date: 9/15/2020
City/State: Westchester, IL
Westchester, IL
Chicago, IL
Danville, IL
Hines, IL
Iron Mountain, MI
Madison, WI
Milwaukee, WI
North Chicago, IL
Tomah, WI
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 leadership performance and oversight by Veterans Integrated Service Network (VISN) 12: VA Great Lakes Health Care System in Westchester, Illinois, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection focused on Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The OIG conducted this unannounced visit during concurrent inspections of VISN 12 facilities.

The VISN executive leadership team appeared stable, with the Deputy Network Director, Chief Medical Officer, Quality Management Officer, and Human Resources Officer having served together for almost two years. The permanent Network Director was appointed on March 1, 2020. Selected survey scores related to employee satisfaction with the VISN executive team leaders were generally better than VHA averages. Overall patient experience survey scores were better than VHA averages; however, the VISN has an opportunity to help improve patient satisfaction with inpatient and specialty care. Executive leaders seemed to support efforts to improve and maintain patient safety, quality care, and other positive outcomes through utilization management training, improvement of hospital-wide readmission rates, and creation of a workgroup to improve case management and follow-up care. The leadership team was knowledgeable within their scope of responsibility about selected Strategic Analytics for Improvement and Learning metrics.

The OIG issued four recommendations for improvement in one area, High-Risk Processes. The OIG recommended that reusable medical equipment inspections are conducted, and results are shared with executive leaders and posted within the required time frame; also, that reusable medical equipment corrective action plans are developed and tracked until closure.