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Comprehensive Healthcare Inspection of Veterans Integrated Service Network 12: VA Great Lakes Health Care System in Westchester, Illinois

Report Information

Issue Date
Report Number
20-00058-250
VISN
12
State
Illinois
Michigan
Wisconsin
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Major Management Challenges
Healthcare Services
Recommendations
4
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
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.

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 Network Director evaluates and determines the reasons for noncompliance and ensures that the Sterile Processing Services Management Board conducts Veterans Integrated Service Network-led facility reusable medical equipment inspections.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that Veterans Integrated Service Network-led facility reusable medical equipment inspection results are provided to executive leaders.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Network Director determines the reasons for noncompliance and ensures that Veterans Integrated Service Network-led facility reusable medical equipment inspection results are posted within the required time frame.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Network Director determines the reasons for noncompliance and ensures that Veterans Integrated Service Network-led reusable medical equipment facility inspection corrective action plans are developed and tracked until closure.