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

Report Information

Issue Date
Closure Date
Report Number
20-00069-222
VISN
12
State
Illinois
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Patient Safety
Medical Staff Privileging Credentialing
Major Management Challenges
Healthcare Services
Recommendations
23
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 Edward Hines, Jr. VA Hospital and multiple outpatient clinics in Illinois. The inspection covers key clinical and administrative processes that are 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. The executive leadership team had worked together for five months at the time of the OIG site visit. The medical center director position had been vacant for five months; the Associate Director had served as acting Director since October 2019. Selected patient experience survey scores generally reflected similar or higher ratings than the VHA average; however, female veterans reported less positive specialty care experiences than female patients nationally. The OIG determined that opportunities exist to improve the institutional disclosure process and considered the vacant director position a vulnerability. Executive leaders were generally knowledgeable within their scopes of responsibilities about data used in Strategic Analytics for Improvement and Learning quality measures and should continue to take actions to sustain and improve performance. The OIG issued 23 recommendations for improvement in six areas: (1) Quality, Safety, and Value • Committee processes • Peer review processes • Utilization management processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit review processes (3) Environment of Care • Expired supplies • Environmental cleanliness (4) Medication Management • Pain screening • Behavior risk assessment • Urine drug testing • Informed consent • Patient follow-up (5) Mental Health • Staff training (6) High-Risk Processes • Bioburden testing • Traffic restriction • Climate control • Staff training • Competency assessments

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: 1/19/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures specific action items are monitored and documented in the Quality Board minutes when problems or opportunities are identified.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that all applicable deaths within 24 hours of admission are peer reviewed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that a summary of the Peer Review Committee’s analyses is reviewed quarterly by the Medical Executive Board.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary reviews of utilization management data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs initiate and complete focused professional practice evaluations on all newly hired licensed independent practitioners.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs include the minimum pathology and radiation oncology specific criteria for ongoing professional practice evaluations of licensed independent practitioners.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs collect, review, and use ongoing professional practice evaluation data in determinations to continue current privileges.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Medical Executive Board’s decisions to recommend initial and continuation of privileges are based on focused and ongoing professional practice evaluation results.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals departing the medical center.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services employees remove expired commercial sterile supplies from service.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2022
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures clinical areas are in good repair and that a safe and clean environment is maintained throughout the medical center.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers complete pain screening for all patients prior to initial dispensing of long-term opioid therapy.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment on all patients prior to initiating long-term opioid therapy.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently obtain and document informed consent for patients who are initiating long-term opioid therapy.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that follow-up with patients receiving long-term opioid therapy include an assessment of adherence to the pain management plan of care and the effectiveness of the intervention.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff receive annual suicide prevention refresher training.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that at least 10 percent of reprocessed endoscopes are tested for bioburden.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2020
The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that traffic flow in the gastroenterology clean storage area is restricted.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services maintains required climate control parameters for areas where reusable medical equipment is reprocessed and stored.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2020
The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures Sterile Processing Services staff complete Level 1 training within 90 days of hire
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Sterile Processing Services Chief complete competency assessments for staff reprocessing reusable medical equipment.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures Sterile Processing Services staff receive monthly continuing education.