Comprehensive Healthcare Inspection Program Review of the VA Illiana Health Care System Danville, Illinois

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Illiana Health Care System (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Credentialing and Privileging; Quality, Safety, and Value (QSV); Environment of Care (EOC); Medication Management: Controlled Substances Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; and Women’s Health: Mammography Results and Follow-Up. The Central Line-Associated Bloodstream Infections special focus area did not apply as the Facility did not have an intensive care unit or emergency department; thus, the OIG focused on the remaining seven areas of clinical operations. The OIG also provided crime awareness briefings to 188 employees. The Facility has generally stable executive leadership and active engagement with employees and patients as evidenced by patient and employee satisfaction scores. Organizational leaders support patient safety, quality care, and initiation of processes and plans to maintain active stakeholder engagement. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors. The OIG noted findings in five of the seven areas of clinical operations reviewed and issued seven recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused Professional Practice Evaluation completion (2) QSV • Utilization Management Committee attendance (3) EOC • EOC rounds attendance • Temperature monitoring in all dry food storage areas (4) Medication Management: Controlled Substances Inspection Program • Staff access to monthly electronic inventory balance adjustments (5) Women’s Health: Mammography Results and Follow-Up • Results electronically linked to radiology order • Communication of test results to patients