Comprehensive Healthcare Inspection of the Jesse Brown VA Medical Center in Chicago, Illinois

Report Information

Issue Date
Report Number
23-00103-138
VISN
12
State
Illinois
Indiana
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Mental Health
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
8
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 Jesse Brown VA Medical Center, which includes multiple outpatient clinics in Illinois and Indiana. 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 eight recommendations for improvement in three areas:
1.    Quality, safety, and value
•    Peer review committee improvement actions
 

2.    Environment of care
•    Environment of care inspections
•    Medical equipment maintenance per manufacturers’ recommendations
•    Medication access by approved individuals using the pneumatic tube system
•    Clean and orderly patient areas
•    Mental health inpatient unit:
    •         Over-the-door alarm testing
    •         Sally port entrance
 

3.    Mental health
•    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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Chief of Staff ensures the Peer Review Committee recommends improvement actions for all peer reviews.

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

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

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

The Associate Director ensures staff maintain all medical equipment in accordance with manufacturers’ recommendations or use an alternative maintenance program that does not reduce the safety of the equipment.

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

The Chief of Staff ensures medications transported by the pneumatic tube system are only accessible by approved individuals.

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

The Associate Director ensures Environmental Management Services staff keep areas used by patients clean and orderly.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff check over-the-door alarms in mental health inpatient units with corridor doors to patient sleeping rooms according to the manufacturer’s guidelines.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures all entrances into mental health inpatient units have a sally port.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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