Submitting OIG:
Report Description:
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Oscar G. Johnson VA Medical Center, which includes multiple outpatient clinics in Michigan and Wisconsin. 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 three recommendations for improvement in two areas:
1. Leadership and organizational risks
• Identification of sentinel events for home oxygen fires
• Veterans Integrated Service Network tracking and monitoring of root cause analyses
2. Mental health
• Completion of Comprehensive Suicide Risk Evaluations
Date Issued:
Wednesday, April 3, 2024
Agency Reviewed / Investigated:
Submitting OIG-Specific Report Number:
23-00111-119
Component, if applicable:
Veterans Health Administration
Location(s):
MI
United StatesWI
United StatesType of Report:
Inspection / Evaluation
Questioned Costs:
$0
Funds for Better Use:
$0
Number of Recommendations:
3
Report updated under NDAA 5274:
No
View Document:
Attachment | Size |
---|---|
VAOIG-23-00111-119.pdf | 3.77 MB |
Additional Details Link: