Comprehensive Healthcare Inspection of the Central Alabama Veterans Health Care System in Montgomery

Report Information

Issue Date
Report Number
23-00106-94
VISN
7
State
Alabama
Georgia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Mental Health
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
2
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 Central Alabama Veterans Health Care System, which includes the Central Alabama VA Medical Center-Montgomery, Central Alabama VA Medical Center-Tuskegee, and multiple outpatient clinics in Alabama and Georgia. 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 two recommendations for improvement in the mental health area of review:
•    Comprehensive Suicide Risk Evaluation completion
•    Suicide-related event reporting

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 providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.

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

The Chief of Staff ensures the Suicide Prevention Coordinator reports suicide-related events monthly to mental health leaders and quality management staff.