Comprehensive Healthcare Inspection of the Gulf Coast Veterans Health Care System in Biloxi, Mississippi

Submitting OIG:

Report Description:

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Gulf Coast Veterans Health Care System in Biloxi, Mississippi. This evaluation focused on five key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care • Mental health (emergency department and urgent care center suicide prevention initiatives) The OIG issued six recommendations for improvement in three areas: 1. Quality, Safety, and Value • Defined governance structure 2. Medical Staff Privileging • Ongoing Professional Practice Evaluations o Service-specific criteria o Data maintained in privileging folders • Evaluations by practitioners with equivalent specialized training and similar privileges • Executive Committee of the Medical Staff review 3. Environment of Care • Clean and safe environment

Date Issued:

Friday, September 29, 2023

Agency Reviewed / Investigated:

Department of Veterans Affairs

Submitting OIG-Specific Report Number:

22-00074-218

Component, if applicable:

Veterans Health Administration

Location(s):

Biloxi, MS

United States

Eglin Air Force Base, FL

United States

Panama City Beach, FL

United States

Pensacola, FL

United States

Mobile, AL

United States

Type of Report:

Review

Questioned Costs:

Funds for Better Use:

Number of Recommendations:

Report updated under NDAA 5274:

View Document:

Attachment	Size
VAOIG-22-00074-218.pdf	3.88 MB

Additional Details Link:

https://www.va.gov/oig/publications/report-summary.asp?id=5361

Recommendation Number	Recommendation Status	Significant Recommendation
01	Open	No
The System Director evaluates and determines any additional reasons for noncompliance and ensures leaders follow their defined governance structure.
02	Open	No
The Chief of Staff determines any additional reasons for noncompliance and ensures leaders use service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
03	Open	No
The Chief of Staff determines any additional reasons for noncompliance and ensures service chiefs maintain Ongoing Professional Practice Evaluation data in licensed independent practitioners’ privileging folders.
04	Open	No
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete professional practice evaluations of licensed independent practitioners.
05	Open	No
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Executive Committee of the Medical Staff reviews the service chiefs’ recommendations along with clinical competence information when making privileging recommendations for licensed independent practitioners.
06	Open	No
The System Director determines any additional reasons for noncompliance and ensures staff maintain a clean and safe environment.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

Open

The System Director evaluates and determines any additional reasons for noncompliance and ensures leaders follow their defined governance structure.

Open

The Chief of Staff determines any additional reasons for noncompliance and ensures leaders use service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

Open

The Chief of Staff determines any additional reasons for noncompliance and ensures service chiefs maintain Ongoing Professional Practice Evaluation data in licensed independent practitioners’ privileging folders.

Open

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete professional practice evaluations of licensed independent practitioners.