Comprehensive Healthcare Inspection of the Boise VA Medical Center in Idaho

Report Information

Issue Date
Report Number
23-00116-148
VISN
20
State
Idaho
Oregon
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Mental Health
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
4
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 Boise VA Medical Center and multiple outpatient clinics in Idaho and Oregon. 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 four recommendations for improvement in two areas:
1.    Environment of care
•    Inpatient Psychiatry Unit panic and over-the-door alarm testing

2.    Mental health
•    Monthly reporting of suicide-related events to mental health leaders and quality management staff
•    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 Medical Center Director ensures staff document VA police response times to panic alarm testing in the Inpatient Psychiatry Unit

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

The Medical Center Director ensures staff follow the manufacturer’s guidelines for checking over-the-door alarms for patient sleeping rooms in the Inpatient Psychiatry Unit.

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

The Medical Center Director ensures the Suicide Prevention Coordinator reports suicide-related events to mental health leaders and quality management staff at least monthly

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

The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.