Federal Reports

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of care delivered at vet centers. This report focused on Midwest district 3 zone 3 and four selected vet centers: Columbia, Missouri; Fargo, North Dakota; Omaha, Nebraska; and Sioux Falls, South Dakota. The OIG inspection focused on five review areas: leadership and organizational risks; quality reviews; suicide prevention; consultation, supervision, and training; and environment of care.Generally, district leaders had a good understanding of quality improvement and implemented quality improvement programs in response to VA All Employee Survey results. District 3 zone 3 Vet Center Service Customer Feedback survey results exceeded national scores. The OIG issued one recommendation to the District Director related to annual training. The OIG closed the recommendation because overdue trainings were completed and future trainings were scheduled.The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policy and procedures. The OIG made two recommendations to the District Director for clinical and administrative quality reviews. The OIG made two recommendations specific to morbidity and mortality reviews: one recommendation to the District Director and one to the Readjustment Counseling Service Chief Officer (RCS).The suicide prevention review included zone-wide evaluation of electronic client records, and a focused review of the four selected vet centers. The OIG issued seven recommendations—six specific to electronic client records and one for selected vet centers’ suicide prevention and intervention processes.The consultation, supervision, and training review evaluated the four selected vet centers. The OIG identified concerns with external clinical consultation, supervision, audits, and training, and issued four recommendations.The environment of care review evaluated the four selected vet centers. The OIG made two recommendations.

This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the outpatient care provided at the El Paso VA Health Care System in Texas. This evaluation focused on four key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of careThe OIG issued three recommendations for improvement in two areas:1. Quality, safety, and value• Patient safety events2. Medical staff privileging• Focused and Ongoing Professional Practice Evaluations