Comprehensive Healthcare Inspection of the Edward Hines, Jr. VA Hospital in Hines, 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 Edward Hines, Jr. VA Hospital and multiple outpatient clinics in Illinois. The inspection covers key clinical and administrative processes that are 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. The executive leadership team had worked together for five months at the time of the OIG site visit. The medical center director position had been vacant for five months; the Associate Director had served as acting Director since October 2019. Selected patient experience survey scores generally reflected similar or higher ratings than the VHA average; however, female veterans reported less positive specialty care experiences than female patients nationally. The OIG determined that opportunities exist to improve the institutional disclosure process and considered the vacant director position a vulnerability. Executive leaders were generally knowledgeable within their scopes of responsibilities about data used in Strategic Analytics for Improvement and Learning quality measures and should continue to take actions to sustain and improve performance. The OIG issued 23 recommendations for improvement in six areas: (1) Quality, Safety, and Value • Committee processes • Peer review processes • Utilization management processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit review processes (3) Environment of Care • Expired supplies • Environmental cleanliness (4) Medication Management • Pain screening • Behavior risk assessment • Urine drug testing • Informed consent • Patient follow-up (5) Mental Health • Staff training (6) High-Risk Processes • Bioburden testing • Traffic restriction • Climate control • Staff training • Competency assessments