This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Iowa City VA Health Care System, which includes the Iowa City VA Medical Center and multiple outpatient clinics in Illinois and Iowa.
This evaluation focused on five key operational areas:
• Leadership and organizational risks
• Quality, safety, and value
• Medical staff privileging
• Environment of care
• Mental health (emergency department and urgent care center suicide prevention initiatives)
The OIG issued six recommendations for improvement in four areas:
1. Leadership and Organizational Risks
• Institutional disclosures for sentinel events
2. Quality, Safety, and Value
• Adverse event investigations
3. Medical Staff Privileging
• Service-specific criteria in Ongoing Professional Practice Evaluations
• Practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations
4. Environment of Care
• Patient areas are clean, safe, and suitable
• Panic alarm testing
Open
Closed-Implemented
Closed-Not ImplementedThe System Director determines any additional reasons for noncompliance and ensures the Chief of Staff conducts institutional disclosures for applicable sentinel events.
The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete adverse event investigations within seven days and document appropriately in the Joint Patient Safety Reporting system, or the Patient Safety Manager monitors the investigations until they are completed.
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete the Ongoing Professional Practice Evaluations of licensed independent practitioners.
The System Director evaluates and determines any additional reasons for noncompliance and ensures managers keep areas used by patients clean, safe, and suitable for the care, treatment, and services provided.
The System Director determines any additional reasons for noncompliance and ensures staff monitor and document VA police response times to panic alarm testing in the Mental Health Inpatient Unit on a regular basis.