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Report File
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Other Participating OIGs
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Components
Veterans Health Administration
Report Number
23-00109-121
Report Description

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 VA Maine Healthcare System, which includes the Togus VA Medical Center and multiple outpatient clinics in Maine. 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 12 recommendations for improvement in all five areas:1. Leadership and organizational risks• Sentinel events and institutional disclosures2. Quality, safety, and value• Root cause analysis for patient safety events3. Medical staff privileging• Ongoing Professional Practice Evaluation data• Focused Professional Practice Evaluation reporting• VISN oversight of credentialing and privileging processes4. Environment of care• Environment of care inspections• Panic and over-the-door alarm testing• Maintaining a safe environment• Hazard warning signs• Safe and clean patient care areas5. Mental health• Comprehensive Suicide Risk Evaluation completion

Report Type
Inspection / Evaluation
Location

ME
United States

Number of Recommendations
5
Questioned Costs
$0
Funds for Better Use
$0
Additional Details
https://www.vaoig.gov/reports/comprehensive-healthcare-inspection-program/compr…

Open Recommendations

This report has 4 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
05 Yes $0 $0

The Veterans Integrated Service Network Chief Medical Officer provides effective oversight of credentialing and privileging processes at the healthcare system.

09 No $0 $0

The Medical Center Director ensures staff maintain a safe environment in the Inpatient Mental Health Unit.

11 No $0 $0

The Medical Center Director ensures staff keep patient care areas safe and clean.

12 No $0 $0

The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.

Department of Veterans Affairs OIG

United States