Comprehensive Healthcare Inspection of the Captain James A. Lovell Federal Health Care Center in North Chicago, Illinois

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Captain James A. Lovell Federal Health Care Center and outpatient clinics in Illinois and Wisconsin. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. At the time of this inspection, the healthcare center’s leaders had been working together for four months. Employee satisfaction survey results revealed opportunities for the Chief Medical Executive and VA Chief Nurse Executive to improve employees’ feelings of “moral distress” at work. Patient experience surveys indicated general satisfaction; however, female veteran scores were less favorable. The leaders were knowledgeable within their scopes of responsibility about Strategic Analytics for Improvement and Learning data and should continue to take action to sustain and improve performance. The OIG issued 27 recommendations for improvement in seven areas: (1) Quality, Safety, and Value • Committee processes • Utilization Management processes (2) Medical Staff Privileging • Focused and ongoing professional practice evaluations • Provider exit reviews (3) Environment of Care • Environmental cleanliness • Privacy and security (4) Medication Management • Quality measure oversight (5) Mental Health • Suicide prevention training (6) Women’s Health • Primary Care Mental Health Integration services • Community-based outpatient clinic women’s health primary care providers • Women Veterans Health Committee membership • Quality data monitoring (7) High-Risk Processes • Standard operating procedures • Annual risk analysis • Airflow testing • Eyewash station testing • Environmental cleanliness • Equipment storage and tracking • Staff training