This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the VA Pacific Islands Health Care System, which includes the Spark M. Matsunaga VA Medical Center in Honolulu and outpatient clinics in Hawaii, Lanai, Maui, Molokai, American Samoa, Guam, and Saipan (Commonwealth of the Northern Mariana Islands).
This evaluation focused on four key operational areas:
• Leadership and organizational risks
• Quality, safety, and value
• Medical staff privileging
• Environment of care
The OIG issued four recommendations for improvement in two areas:
1. Medical Staff Privileging
• Ongoing Professional Practice Evaluations
o Equivalent specialized training and similar privileges
o Service-specific criteria
o Continuation of privileges based on results
2. Environment of Care
• Inpatient mental health unit environmental safety requirements
Open
Closed-Implemented
Closed-Not ImplementedThe Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
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 the Executive Committee of the Medical Staff recommends continuation of privileges based on Ongoing Professional Practice Evaluation results.
The Assistant Director for Efficiency and Improvement evaluates and determines any additional reasons for noncompliance and ensures managers comply with inpatient mental health unit environmental safety requirements.