Comprehensive Healthcare Inspection of the Roseburg VA Health Care System in Oregon

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 Roseburg VA Health Care System, which includes the Roseburg VA Medical Center and multiple outpatient clinics in Oregon. 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 11 recommendations for improvement in four areas: 1. Leadership and organizational risks • Root cause analyses for sentinel events 2. Medical staff privileging • Focused and Ongoing Professional Practice Evaluation completion • Ongoing Professional Practice Evaluations o Specialty-specific data o Equivalent specialized training and similar privileges • Executive committee review of professional practice evaluation results • VISN oversight of privileging processes 3. Environment of care • Panic and over-the-door alarm testing in the mental health inpatient unit 4. Mental health • Comprehensive Suicide Risk Evaluation completion • Reporting of suicide behaviors to suicide prevention team • Suicide prevention outreach activities

Date Issued:

Wednesday, May 15, 2024

Agency Reviewed / Investigated:

Department of Veterans Affairs

Submitting OIG-Specific Report Number:

23-00110-168

Component, if applicable:

Veterans Health Administration

Location(s):

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-23-00110-168.pdf	2.22 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	No
The Executive Director ensures staff complete root cause analyses for sentinel events.
02	Open	No
The Chief of Staff ensures service chiefs initiate Focused Professional Practice Evaluations for newly appointed licensed independent practitioners.
03	Open	No
The Chief of Staff ensures service chiefs regularly complete Ongoing Professional Practice Evaluations for licensed independent practitioners.
04	Open	No
The Chief of Staff ensures service chiefs consider specialty-specific data during licensed independent practitioners’ Ongoing Professional Practice Evaluations.
05	Open	No
The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations.
06	Open	No
The Chief of Staff ensures the Healthcare Delivery Council or an appropriately identified executive committee of the medical staff reviews professional practice evaluation results.
07	Open	No
The Veterans Integrated Service Network Chief Medical Officer oversees the healthcare system’s privileging processes.
08	Open	No
The Executive Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms for sleeping rooms in the Acute Psychiatric Unit.
09	Open	No
The Executive Director ensures staff test panic alarms in the Acute Psychiatric Unit and document VA police response times.
10	Open	No
The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

Open

The Executive Director ensures staff complete root cause analyses for sentinel events.

Open

The Chief of Staff ensures service chiefs initiate Focused Professional Practice Evaluations for newly appointed licensed independent practitioners.

Open

The Chief of Staff ensures service chiefs regularly complete Ongoing Professional Practice Evaluations for licensed independent practitioners.

Open

The Chief of Staff ensures service chiefs consider specialty-specific data during licensed independent practitioners’ Ongoing Professional Practice Evaluations.