Comprehensive Healthcare Inspection of the Alaska VA Healthcare System in Anchorage

Report Information

Issue Date
Report Number
23-00017-81
VISN
20
State
Alaska
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Mental Health
Patient Care Services Operations
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 care provided at the Alaska VA Healthcare System, which includes the Colonel Mary Louise Rasmuson Campus in Anchorage and other outpatient clinics in Alaska. 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.    Environment of care
•    Temperature and humidity monitoring

2.    Mental health
•    Suicide-related event reporting
•    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 Executive Director ensures Supply Chain Management, Engineering, or Facility Management Service staff monitor temperature and humidity in all clean and sterile storage rooms to maintain a stable environment.

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

The Executive Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to quality management staff.

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

The Executive Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a positive suicide risk screen in ambulatory care settings.