Comprehensive Healthcare Inspection of the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia

Report Information

Issue Date
Report Number
23-00108-149
VISN
5
State
West Virginia
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
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
6
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 Louis A. Johnson VA Medical Center, which includes multiple outpatient clinics in West Virginia. 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 six recommendations for improvement in three areas:
1.    Medical staff privileging
•    Professional Practice Evaluation reviews and recommendations

2.    Environment of care
•    Safe and clean patient care areas
•    Mental health inpatient unit:
    •         Panic alarm testing
    •         Maintaining a safe environment
•    Safe environment for mental health patients in the Emergency Department

3.    Mental health
•    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 service chiefs document professional practice evaluation results in practitioners’ profiles, and the Medical Executive Committee reviews service chiefs’ recommendations along with clinical competence information when making privileging recommendations to the Director.

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

The Associate Director ensures staff keep patient care areas safe and clean.

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

The Director ensures staff regularly test panic alarms in the mental health inpatient unit and document VA police response times.

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

The Director ensures staff maintain a safe environment in the mental health inpatient unit.

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

The Director ensures staff maintain a safe environment in the Emergency Department for mental health patients.

No. 6
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.