Comprehensive Healthcare Inspection of the St. Cloud VA Health Care System in Minnesota

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 St. Cloud VA Health Care System, which includes the St. Cloud VA Medical Center and multiple outpatient clinics in Minnesota. 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 two recommendations for improvement in two areas: 1. Leadership and Organizational Risks • Institutional disclosures for sentinel events 2. Mental Health • Suicide safety plans for patients with positive suicide risk screens