Comprehensive Healthcare Inspection of the Oscar G. Johnson VA Medical Center in Iron Mountain, Michigan

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
Mental Health
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Questioned Costs
Better Use of Funds
Congressionally Mandated



This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Oscar G. Johnson VA Medical Center, which includes multiple outpatient clinics in Michigan and Wisconsin. 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 three recommendations for improvement in two areas:
1.    Leadership and organizational risks
•    Identification of sentinel events for home oxygen fires
•    Veterans Integrated Service Network tracking and monitoring of root cause analyses

2.    Mental health
•    Completion of Comprehensive Suicide Risk Evaluations

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 Medical Center Director ensures staff identify sentinel events and take appropriate action when home oxygen fires occur.

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

The Veterans Integrated Service Network Director ensures network staff track and monitor home oxygen vendor completion of root cause analyses when sentinel events occur.

No. 3
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.