Comprehensive Healthcare Inspection of the Central Arkansas Veterans Healthcare System in Little Rock

Report Information

Issue Date
Closure Date
Report Number
22-00076-222
VISN
1
State
Arkansas
District
Continental
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Major Management Challenges
Benefits for Veterans
Recommendations
5
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 inpatient and outpatient care provided at the Central Arkansas Veterans Healthcare System, which includes the John L. McClellan Memorial Veterans’ Hospital (Little Rock), Eugene J. Towbin Healthcare Center (North Little Rock), and multiple outpatient clinics in Arkansas. This evaluation focused on five key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care • Mental health (emergency department and urgent care center suicide prevention initiatives) The OIG issued five recommendations for improvement in three areas: 1. Quality, Safety, and Value • Root cause analysis 2. Medical Staff Privileging • Defined time frames for Focused Professional Practice Evaluations 3. Mental Health • Comprehensive Suicide Risk Evaluations • Suicide safety plans • Follow-up for patients at risk for suicide

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: 9/29/2023
The Director determines the reasons for noncompliance and ensures staff complete an individual root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2024

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define time frames for Focused Professional Practice Evaluations.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2023
The Director evaluates and determines any additional reasons for noncompliance and ensures clinicians complete a Comprehensive Suicide Risk Evaluation following a positive suicide risk screen for patients seen in the Emergency Department.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2024

The Director evaluates and determines any additional reasons for noncompliance and ensures clinicians create or update a suicide safety plan for patients determined to be at intermediate, high-acute, or chronic risk-for-suicide and safe to discharge home from the Emergency Department.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2024

The Director evaluates and determines any additional reasons for noncompliance and ensures clinicians follow up within seven days with patients determined to be at intermediate, high-acute, or chronic risk-for-suicide who were discharged home from the Emergency Department.