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Comprehensive Healthcare Inspection of the VA North Texas Health Care System in Dallas

Submitting OIG: 
Department of Veterans Affairs OIG
Report Description: 
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 North Texas Health Care System, which includes the Dallas VA Medical Center, Garland VA Medical Center, Sam Rayburn Memorial Veterans Center (Bonham), and multiple outpatient clinics in Texas. 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 2. Mental health • Follow-up for patients at risk for suicide
Date Issued: 
Tuesday, June 6, 2023
Agency Reviewed / Investigated: 
Department of Veterans Affairs
Submitting OIG-Specific Report Number: 
22-00038-125
Component, if applicable: 
Veterans Health Administration
Location(s): 
Dallas, TX
United States
Garland, TX
United States
Bonham, TX
United States
Decatur, TX
United States
Denton, TX
United States
Fort Worth, TX
United States
Granbury, TX
United States
Grand Prairie, TX
United States
Greenville, TX
United States
Plano, TX
United States
Sherman, TX
United States
Tyler, TX
United States
Type of Report: 
Review
Questioned Costs: 
$0
Funds for Better Use: 
$0
Number of Recommendations: 
2
View Document: 
AttachmentSize
PDF icon VAOIG-22-00038-125.pdf3.54 MB
Additional Details Link: 
https://www.va.gov/oig/publications/report-summary.asp?id=5289

Related Open Recommendations

Recommendation Number Recommendation Status Significant Recommendation Additional Details
01 Open No
The Executive Director evaluates and determines additional reasons for noncompliance and ensures leaders conduct and accurately document institutional disclosures for applicable sentinel events.
01 Open No
The Executive Director evaluates and determines additional reasons for noncompliance and ensures leaders conduct and accurately document institutional disclosures for applicable sentinel events.
02 Open No
The Assistant Director Clinical Services evaluates and determines any additional reasons for noncompliance and ensures mental health staff attempt weekly follow-up until care is established for patients discharged from the emergency department who are at intermediate or high acute or chronic risk of suicide.
02 Open No
The Assistant Director Clinical Services evaluates and determines any additional reasons for noncompliance and ensures mental health staff attempt weekly follow-up until care is established for patients discharged from the emergency department who are at intermediate or high acute or chronic risk of suicide.
Displaying 4 of 4 Recommendations