Comprehensive Healthcare Inspection of the Manchester VA Medical Center in New Hampshire

Report Information

Issue Date
Report Number
22-03157-95
VISN
1
State
New Hampshire
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
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
6
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 outpatient settings of the Manchester VA Medical Center, which includes multiple outpatient clinics in New Hampshire. 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 six recommendations for improvement in three areas:
1.    Medical staff privileging
•    Medical Executive Council reviews of professional practice evaluations
•    Equivalent specialized training and similar privileges
•    Veterans Integrated Service Network oversight

2.    Environment of care
•    Inspections
•    Clean and safe patient areas

3.    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
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures the Medical Executive Council reviews results of professional practice evaluations.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete licensed independent practitioners’ professional practice evaluations.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures the Veterans Integrated Service Network Chief Medical Officer provides oversight of the medical center’s privileging process.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures the Comprehensive Environment of Care Coordinator or designee schedules environment of care inspections and staff complete and document them at the required frequency.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director 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.