Comprehensive Healthcare Inspection of the Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri

Report Information

Issue Date
Report Number
23-00112-161
VISN
15
State
Missouri
District
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Medical Staff Privileging Credentialing
Mental Health
Patient Safety
Suicide Prevention
Recommendations
7
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 Harry S. Truman Memorial Veterans’ Hospital, which includes multiple outpatient clinics in Missouri. 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 seven recommendations for improvement in three areas:
1.    Medical staff privileging
•    Ongoing Professional Practice Evaluation
o    Completion
o    Service-specific criteria
•    Professional practice evaluation data

2.    Environment of care
•    Mental health inpatient unit over-the-door alarm testing

3.    Mental health
•    Comprehensive Suicide Risk Evaluation completion
•    Suicide prevention outreach activities
•    Reporting suicide behaviors to the suicide prevention team
 

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 service chiefs regularly complete Ongoing Professional Practice Evaluations for licensed independent practitioners.

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

The Chief of Staff ensures the Clinical Executive Board reviews professional practice evaluation data for licensed independent practitioners.

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

The Chief of Staff ensures service chiefs include service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

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

The Medical Center Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on mental health inpatient unit sleeping room doors.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures suicide prevention coordinators conduct, track, and report a minimum of five suicide prevention outreach activities each month.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.