Comprehensive Healthcare Inspection of the San Francisco VA Health Care System in California

Report Information

Issue Date
Closure Date
Report Number
22-00231-176
VISN
1
State
California
District
Continental
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
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 inpatient and outpatient care provided at the San Francisco VA Health Care System, which includes the San Francisco VA Medical Center and multiple outpatient clinics in California. This evaluation focused on five key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care • Mental health (focusing on emergency department and urgent care center suicide prevention initiatives) The OIG issued five recommendations for improvement in four areas: 1. Leadership and Organizational Risks • Institutional disclosures for sentinel events 2. Quality, Safety, and Value • Improvement actions for peer reviews • Root cause analysis for patient safety events 3. Medical Staff Privileging • Ongoing Professional Practice Evaluation results and privileging decisions 4. Environment of Care • Expired supplies in supply rooms

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)
Closure Date: 6/28/2024

The Health Care System Director determines the reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2024

The Health Care System Director evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for all Level 3 peer reviews, and supervisors ensure implementation of those actions.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2024

The Health Care System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager conducts a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2024

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee reviews Ongoing Professional Practice Evaluation results and documents privileging decisions in the meeting minutes.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2024

The Associate Director for Patient Care Services/Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures staff check supply rooms for expired supplies and discard them.