Comprehensive Healthcare Inspection of the Captain James A. Lovell Federal Health Care Center in North Chicago, Illinois

Report Information

Issue Date
Closure Date
Report Number
20-00064-238
VISN
12
State
Illinois
Wisconsin
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Medical Staff Privileging Credentialing
Major Management Challenges
Healthcare Services
Recommendations
27
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 quality of care delivered in the inpatient and outpatient settings of the Captain James A. Lovell Federal Health Care Center and outpatient clinics in Illinois and Wisconsin. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection focused on 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. At the time of this inspection, the healthcare center’s leaders had been working together for four months. Employee satisfaction survey results revealed opportunities for the Chief Medical Executive and VA Chief Nurse Executive to improve employees’ feelings of “moral distress” at work. Patient experience surveys indicated general satisfaction; however, female veteran scores were less favorable. The leaders were knowledgeable within their scopes of responsibility about Strategic Analytics for Improvement and Learning data and should continue to take action to sustain and improve performance. The OIG issued 27 recommendations for improvement in seven areas: (1) Quality, Safety, and Value • Committee processes • Utilization Management processes (2) Medical Staff Privileging • Focused and ongoing professional practice evaluations • Provider exit reviews (3) Environment of Care • Environmental cleanliness • Privacy and security (4) Medication Management • Quality measure oversight (5) Mental Health • Suicide prevention training (6) Women’s Health • Primary Care Mental Health Integration services • Community-based outpatient clinic women’s health primary care providers • Women Veterans Health Committee membership • Quality data monitoring (7) High-Risk Processes • Standard operating procedures • Annual risk analysis • Airflow testing • Eyewash station testing • Environmental cleanliness • Equipment storage and tracking • Staff training

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)
Closure Date: 2/16/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and ensures improvement action items recommended by the Quality Council are fully implemented and monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and makes certain the Patient Flow Committee meeting minutes reflect documentation, implementation, and evaluation of action items.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs define in advance, communicate, and document expectations for focused professional practice evaluations in provider profiles.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures service chiefs document focused professional practice evaluation results in provider profiles.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and makes certain that the Executive Committee of the Medical Staff meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend continuation of initially granted privileges.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation criteria.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete licensed independent practitioners’ ongoing professional practice evaluations.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the licensed healthcare professional’s first- or second-line supervisor completes and signs the exit review form within seven calendar days of the professional’s departure from the center.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that healthcare center managers repair or remove damaged wheelchairs from service.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that healthcare center managers maintain a safe and clean environment.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures adequate privacy is provided in patient examination rooms at the Evanston VA Clinic.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures the information technology room at the Evanston VA Clinic is secure and restricted to authorized personnel.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and ensures the Pain Management Committee monitors the quality of pain assessments and the effectiveness of pain management interventions.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The Healthcare Center Director determines the reasons for noncompliance and ensures clinical and nonclinical staff complete annual suicide prevention refresher training.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and ensures that clinicians at community-based outpatient clinics provide integrated mental health services for women veterans.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and makes certain that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage when clinics have only one provider.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned and consistently attend Women Veterans Health Committee meetings.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures the Women’s Health Medical Director collects, tracks, and reports quality assurance data.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services aligns standard operating procedures with manufacturers’ guidelines and instructions for use.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Sterile Processing Services enters all equipment into the CensiTrac® Instrument Tracking System.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services consistently reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff conduct annual airflow testing in all areas where reusable medical equipment is reprocessed or stored.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Engineering Service or designee conduct and maintain the record of weekly eyewash station function testing.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Associate Director for Facilities Support determines the reasons for noncompliance and makes certain the Environmental Management Supervisor develop, implement, and enforce a written cleaning schedule for all Sterile Processing Services areas.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that endoscopes are properly stored by Sterile Processing Services and clinical staff.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff properly complete competency assessments for reprocessing reusable medical equipment.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services staff receive monthly continuing education.