VA review of Iowa City VA Health Care System

Review of Quality of Care, Management, and Operations, Iowa City VA Health Care System
Iowa City, IA
August 29, 2012

Executive Summary
The VA Office of Inspector General Office of Healthcare Inspections conducted a comprehensive review of the Iowa City VA Health Care System in response to a request from Senator Charles E. Grassley. OIG assessed the merit of allegations about quality of care and that concerns expressed by staff “have been largely ignored.”

All system employees were invited to respond anonymously to a survey about patient care and working conditions through a dedicated OIG internet portal. Individuals responding to the survey could, if they wished, provide specific details and contact information.

Analysis of responses to the survey afforded an opportunity to focus on issues that might otherwise receive less attention.

During two site visits, OIG staff inspected the parent facility and two Community Based Outpatient Clinics, and conducted scheduled and unscheduled interviews with approximately 125 individuals, including senior leaders, mid-level managers, front line employees, patients, and volunteers.

We found that high quality medical care has been maintained. However, we also found that a pervasive lack of support for staff problem-solving is a potential threat to patient safety, and that several process deficiencies were identified. During a prolonged period when key leadership positions were held by individuals on a temporary basis, decisions were delayed or never made, and a highly competent professional staff was frustrated by the persistent ineffectiveness of senior leadership.

We recommended that the Veterans Integrated Service Network Director ensure that system leaders take appropriate action in response to identified problems and communicate action plans to staff. We also recommended that system leaders clarify organizational lines of authority and responsibility and improve components of Environment of Care and Pharmacy management.
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