Comprehensive Healthcare Inspection of the Iowa City VA Health Care System in Iowa

Submitting OIG:

Report Description:

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

Date Issued:

Thursday, November 2, 2023

Agency Reviewed / Investigated:

Department of Veterans Affairs

Submitting OIG-Specific Report Number:

22-02667-09

Component, if applicable:

Veterans Health Administration

Location(s):

Iowa City, IA

United States

Type of Report:

Review

Questioned Costs:

Funds for Better Use:

Number of Recommendations:

Report updated under NDAA 5274:

View Document:

Attachment	Size
vaoig-22-02667-09.pdf	4.02 MB

Additional Details Link:

https://www.vaoig.gov/reports/comprehensive-healthcare-inspection-program/compre…

Recommendation Number	Recommendation Status	Significant Recommendation
01	Open	No
The System Director determines any additional reasons for noncompliance and ensures the Chief of Staff conducts institutional disclosures for applicable sentinel events.
02	Open	No
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.
03	Open	No
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.
04	Open	No
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.
05	Open	No
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.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

Open

The System Director determines any additional reasons for noncompliance and ensures the Chief of Staff conducts institutional disclosures for applicable sentinel events.

Open

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.

Open

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.

Open

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.