Comprehensive Healthcare Inspection of the Oscar G. Johnson VA Medical Center in Iron Mountain, Michigan
Report Information
Summary
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
The Medical Center Director ensures staff identify sentinel events and take appropriate action when home oxygen fires occur.
The Veterans Integrated Service Network Director ensures network staff track and monitor home oxygen vendor completion of root cause analyses when sentinel events occur.
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.