Comprehensive Healthcare Inspection of the Kansas City VA Medical Center in Missouri

Submitting OIG:

Report Description:

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Kansas City VA Medical Center, which includes multiple outpatient clinics in Kansas and Missouri. This evaluation focused on five key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care • Mental health (suicide prevention initiatives) The OIG issued five recommendations for improvement in three areas: 1. Leadership and organizational risks • Institutional disclosures for sentinel events 2. Environment of care • Environment of care inspections • Electrical receptacles covered with metal plates in the Inpatient Mental Health Unit 3. Mental health • Comprehensive Suicide Risk Evaluation completion • Suicide behaviors reported to suicide prevention team

Date Issued:

Thursday, April 25, 2024

Agency Reviewed / Investigated:

Department of Veterans Affairs

Submitting OIG-Specific Report Number:

23-00119-156

Component, if applicable:

Veterans Health Administration

Location(s):

Kansas City, MO

United States

Type of Report:

Inspection / Evaluation

Questioned Costs:

Funds for Better Use:

Number of Recommendations:

Report updated under NDAA 5274:

View Document:

Attachment	Size
VAOIG-23-00119-156.pdf	3.22 MB

Additional Details Link:

https://www.vaoig.gov/reports/comprehensive-healthcare-inspection-program/compre…

Related Open Recommendations

Recommendation Number	Recommendation Status	Significant Recommendation
01	Open	Yes
The facility will provide a copy of the Risk Manager’s spreadsheet used to track institutional disclosures, list of sentinel events, list of institutional disclosures conducted, six consecutive months of Quality and Patient Safety Council meeting minutes with attachments and six consecutive months of JPSR data.
02	Open	Yes
The Medical Center Director ensures staff complete environment of care inspections in patient and non-patient care areas at the required frequency.
03	Open	Yes
The Medical Center Director ensures staff cover electrical receptacles in the Inpatient Mental Health Unit common area with metal plates.
04	Open	Yes
The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.
05	Open	Yes
The Medical Center Director ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during Comprehensive Suicide Risk Evaluations.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

Open

Yes

The facility will provide a copy of the Risk Manager’s spreadsheet used to track institutional disclosures, list of sentinel events, list of institutional disclosures conducted, six consecutive months of Quality and Patient Safety Council meeting minutes with attachments and six consecutive months of JPSR data.

Open

Yes

The Medical Center Director ensures staff complete environment of care inspections in patient and non-patient care areas at the required frequency.

Open

Yes