Comprehensive Healthcare Inspection of the San Francisco VA Health Care System in California

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the San Francisco VA Health Care System, which includes the San Francisco VA Medical Center and multiple outpatient clinics in 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 five recommendations for improvement in four areas:1. Leadership and Organizational Risks• Institutional disclosures for sentinel events2. Quality, Safety, and Value• Improvement actions for peer reviews• Root cause analysis for patient safety events3. Medical Staff Privileging• Ongoing Professional Practice Evaluation results and privileging decisions4. Environment of Care• Expired supplies in supply rooms