Comprehensive Healthcare Inspection of the VA Central Iowa Health Care System in Des Moines

Report Information

Issue Date
Closure Date
Report Number
23-00096-122
VISN
23
State
Iowa
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Medical Staff Privileging Credentialing
Mental Health
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

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 Central Iowa Health Care System, which includes the Des Moines VA Medical Center and multiple outpatient clinics in Iowa. 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 three recommendations for improvement in two areas:
1.    Medical staff privileging
•    Ongoing Professional Practice Evaluations by providers with equivalent specialized training and similar privileges
•    Ongoing Professional Practice Evaluation activities

2.    Mental health
•    Comprehensive Suicide Risk Evaluation completion

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2024

The Chief of Staff ensures providers with equivalent specialized training and similar privileges complete licensed independent practitioners’ Ongoing Professional Practice Evaluations.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2024

The Chief of Staff ensures service chiefs recommend continued privileges for licensed independent practitioners based, in part, on Ongoing Professional Practice Evaluation activities.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2025

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in ambulatory care settings.