Comprehensive Healthcare Inspection of the VA Palo Alto 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 VA Palo Alto Health Care System, which includes medical centers in Palo Alto, Menlo Park, and Livermore 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 four recommendations for improvement in two areas:1. Leadership and Organizational Risks• Institutional disclosures for sentinel events2. Environment of Care• Preventive maintenance on medical equipment• Access to medications only by authorized staff• Clean and safe environment