Comprehensive Healthcare Inspection of the Kansas City VA Medical Center in Missouri

Report Information

Issue Date
Report Number
23-00119-156
VISN
15
State
Kansas
Missouri
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
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 Kansas City VA Medical Center, which includes multiple outpatient clinics in Kansas and 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 five recommendations for improvement in three areas:
1.    Leadership and organizational risks
•    Institutional disclosures for sentinel events

2.    Environment of care
•    Environment of care inspections
•    Electrical receptacles covered with metal plates in the Inpatient Mental Health Unit

3.    Mental health
•    Comprehensive Suicide Risk Evaluation completion
•    Suicide behaviors reported to 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 Medical Center Director ensures leaders conduct institutional disclosures for all applicable sentinel events.

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

The Medical Center Director ensures staff complete environment of care inspections in patient and non-patient care areas at the required frequency.

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

The Medical Center Director ensures staff cover electrical receptacles in the Inpatient Mental Health Unit common area with metal plates.

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.

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

The Medical Center Director ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during Comprehensive Suicide Risk Evaluations.