Comprehensive Healthcare Inspection of the Mountain Home VA Healthcare System in Tennessee

Report Information

Issue Date
Report Number
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Patient Safety
Major Management Challenges
Healthcare Services
Leadership and Governance
Questioned Costs
Better Use of Funds
Congressionally Mandated


This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Mountain Home VA Healthcare System, which includes the James H. Quillen VA Medical Center and multiple outpatient clinics in Tennessee and Virginia. This evaluation focused on five key areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care • Mental health (emergency department and urgent care center suicide prevention initiatives) At the time of the inspection, the system’s executive leaders had worked together for over three years. The healthcare system’s fiscal year 2021 annual medical care budget increased over 9 percent compared to the previous year’s budget. The System Director reported using the additional funds to support staffing increases and to expand inpatient capacity and outpatient services. The OIG reviewed employee satisfaction survey results and concluded that the System Director had an opportunity to improve staff’s perceived ability to disclose suspected violations without fear of reprisal. Inpatient and outpatient experience survey scores reflected higher care ratings than the VHA averages, but trended downward in primary care from fiscal years 2019 through 2021. The OIG reviewed accreditation findings and did not identify any substantial organizational risk factors. However, the OIG noted concerns with system leaders identifying sentinel events and issued one related recommendation for improvement.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director determines the reasons for noncompliance and ensures leaders identify adverse events as sentinel events when criteria are met.