Comprehensive Healthcare Inspection of the Oscar G. Johnson VA Medical Center in Iron Mountain, Michigan

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Oscar G. Johnson VA Medical Center, which includes multiple outpatient clinics in Michigan and Wisconsin. 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 three recommendations for improvement in two areas:1. Leadership and organizational risks• Identification of sentinel events for home oxygen fires• Veterans Integrated Service Network tracking and monitoring of root cause analyses2. Mental health• Completion of Comprehensive Suicide Risk Evaluations