Comprehensive Healthcare Inspection of the Cheyenne VA Medical Center in Wyoming

Report Information

Issue Date
Report Number
23-00122-118
VISN
19
State
Colorado
Nebraska
Wyoming
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
Suicide Prevention
Major Management Challenges
Healthcare Services
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 quality of care delivered in the inpatient and outpatient settings of the Cheyenne VA Medical Center and multiple outpatient clinics in Colorado, Nebraska, and Wyoming. 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 five recommendations for improvement in three areas:
1.    Medical staff privileging
•    Focused Professional Practice Evaluation results review
•    Ongoing Professional Practice Evaluation completion

2.    Environment of care
•    Environment of care inspections

3.    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 Chief of Staff ensures medical staff review and document licensed independent practitioners’ Focused Professional Practice Evaluation results and report them to the Medical Executive Board.

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

The Chief of Staff ensures service chiefs monitor licensed independent practitioners’ performance by regularly conducting Ongoing Professional Practice Evaluations.

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

The Medical Center Director ensures staff conduct environment of care inspections in patient care areas at the required frequency.

No. 4
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. 5
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.