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 Bay Pines VA Healthcare System, which includes the C.W. Bill Young VA Medical Center and eight outpatient clinics in Florida. 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 eight recommendations for improvement in four areas:1. Leadership and organizational risks• Institutional disclosures for sentinel events2. Quality, safety, and value• Root cause analysis for patient safety events3. Environment of care• Clean and orderly patient care areas• Furnishings and walls in good repair• Solid bottom shelves in storage areas• Medical equipment inspection, testing, and maintenance • Mental health inpatient unit panic alarm testing4. Mental health• Monthly reporting of suicide events to quality management staff
Bay Pines,
United States