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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
22-00063-220
Report Description

This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the VA Northern California Health Care System, which includes the Sacramento VA Medical Center, Martinez VA Medical Center, an outpatient clinic at Travis Air Force Base, and other 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 (emergency department and urgent care center suicide prevention initiatives)The OIG issued seven recommendations for improvement in three areas:1. Medical Staff Privileging• Evaluation result documentation and reporting• Reprivileging recommendations based on service-specific Ongoing Professional Practice Evaluation data2. Environment of Care• Panic and over-the-door alarm testing in the inpatient mental health unit• Cleanliness, furnishings, and equipment• Properly stored and secured medications3. Mental Health• Timely follow-up for patients at risk for suicide discharged from the Emergency Department

Report Type
Review
Location

Chico, CA
United States

Yreka, CA
United States

Auburn, CA
United States

Mather, CA
United States

Sonora, CA
United States

Modesto, CA
United States

Redding, CA
United States

Martinez, CA
United States

Yuba City, CA
United States

Travis AFB, CA
United States

French Camp, CA
United States

McClellan Park, CA
United States

Number of Recommendations
5
Questioned Costs
$0
Funds for Better Use
$0

Department of Veterans Affairs OIG

United States