Comprehensive Healthcare Inspection of the VA Loma Linda Healthcare System in California

Report Information

Issue Date
Closure Date
Report Number
22-00048-120
VISN
22
State
California
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
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
5
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
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 Loma Linda Healthcare System, which includes the Jerry L. Pettis Memorial Veterans’ Hospital and multiple outpatient clinics in California. 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 five recommendations for improvement in three areas: 1. Leadership and organizational risks • Sentinel events and institutional disclosures 2. Quality, safety, and value • Adverse events 3. Medical staff privileging • Focused Professional Practice Evaluation processes • Reprivileging reviews

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: 7/22/2024

The Director evaluates and determines reasons for noncompliance and ensures leaders evaluate sentinel events and conduct institutional disclosures when criteria are met.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

The Director evaluates and determines any additional reasons for noncompliance and ensures that for all events assigned an actual or potential safety assessment code score of three, staff either complete an individual root cause analysis or include the event in an aggregated patient safety review.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2024

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers use Focused Professional Practice Evaluation criteria that are defined in advance and accepted by the practitioner.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2024

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain clinical managers define time frames for Focused Professional Practice Evaluations.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2024

The Chief of Staff evaluates and determines any additional reasons for noncompliance and verifies that the Medical Executive Council’s meeting minutes consistently reflect the data reviewed for licensed independent practitioners’ re-privileging requests and the rationale for the recommendations.