Comprehensive Healthcare Inspection of the Roseburg VA Health Care System in Oregon

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 Roseburg VA Health Care System, which includes the Roseburg VA Medical Center and multiple outpatient clinics in Oregon. 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 11 recommendations for improvement in four areas:1. Leadership and organizational risks• Root cause analyses for sentinel events2. Medical staff privileging• Focused and Ongoing Professional Practice Evaluation completion• Ongoing Professional Practice Evaluationso Specialty-specific datao Equivalent specialized training and similar privileges• Executive committee review of professional practice evaluation results• VISN oversight of privileging processes3. Environment of care• Panic and over-the-door alarm testing in the mental health inpatient unit4. Mental health• Comprehensive Suicide Risk Evaluation completion• Reporting of suicide behaviors to suicide prevention team• Suicide prevention outreach activities