Comprehensive Healthcare Inspection of the VA Greater Los Angeles Healthcare System in California

This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the VA Greater Los Angeles Healthcare System, which includes the West Los Angeles VA Medical Center and multiple outpatient clinics throughout California. This evaluation focused on five key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care • Mental health (focusing on emergency department and urgent care center suicide prevention initiatives) The OIG issued nine recommendations for improvement in three areas: 1. Quality, Safety, and Value • Peer review improvement actions • Patient safety event root cause analysis 2. Medical Staff Privileging • Focused Professional Practice Evaluation time frames • Ongoing Professional Practice Evaluation service-specific criteria • Privileging request recommendations in Medical Executive Council meeting minutes 3. Environment of Care • Inspecting, testing, and maintaining medical equipment • Maintaining equipment and furnishings and keeping patient care areas clean and safe • Using breathable shower curtains in mental health inpatient unit bathrooms • Recording and accessing video or audio monitoring equipment