www.va.govReport Summary
Combined Assessment Program Review of the Jesse Brown VA Medical Center Chicago, Illinois
Report Number 08-00003-10, 10/17/2008 | Full Report (PDF)
The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). We also provided fraud and integrity awareness briefings to 143 medical center employees. The review covered eight operational activities. The medical center complied with selected standards in the following three areas: (1) pharmacy operations, (2) staffing, and (3) survey of healthcare experiences of patients. We made recommendations for improvements in the following activities: QM – Implement a provider-specific performance information process to assess competency and support privileging decisions; document committee attendance and discussion to support credentialing and privileging (C&P) decisions; ensure C&P folders and documentation meet requirements; and meet peer review timeliness requirements and ensure providers review all cases meeting criteria.
Medication Management – Consistently document pain medication effectiveness within the required timeframe. Emergency Department (ED) Operations – Complete ED inter-facility transfer documentation. Coordination of Care – Consistently complete intra-facility transfer and discharge documentation. Environment of Care (EOC) – Check emergency carts; monitor refrigerators; display suicide prevention posters and brochures in highly visible areas; update the local hand hygiene policy and consistently collect compliance data; conduct EOC rounds weekly and inspect all areas at least semi-annually; develop action plans for EOC deficiencies; and ensure all inpatient psychiatric staff receive training on environmental hazards that pose a threat to suicidal patients.