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

Report Information

Issue Date
Report Number
23-00118-157
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
Medical Staff Privileging Credentialing
Mental Health
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
5
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Edward Hines, Jr. VA Hospital, which includes multiple outpatient clinics in Illinois. This evaluation focused on five key operational areas:
•    Leadership and organizational risks
•    Quality, safety, and value
•    Medical staff privileging
•    Environment of care
•    Mental health (suicide prevention initiatives)

The OIG issued five recommendations for improvement in three areas:
1.    Medical staff privileging
•    VISN oversight of privileging process

2.    Environment of care
•    Environment of care inspections

3.    Mental health
•    Suicide prevention outreach activities
•    Monthly reporting of suicide-related events
•    Comprehensive Suicide Risk Evaluation completion
 

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures the Veterans Integrated Service Network Chief Medical Officer oversees the hospital’s privileging process.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Hospital Director ensures staff conduct environment of care inspections in non patient care areas at least once per fiscal year.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Hospital Director ensures the suicide prevention team conducts a minimum of five outreach activities per month.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Hospital Director ensures the suicide prevention coordinators report suicide related events monthly to mental health leaders and quality management staff.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Hospital Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.