Comprehensive Healthcare Inspection of the VA Black Hills Health Care System in Fort Meade, South Dakota

Report Information

Issue Date
Report Number
23-00097-113
VISN
23
State
Nebraska
North Dakota
South Dakota
Wyoming
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
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
4
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 VA Black Hills Health Care System, which includes the Fort Meade and Hot Springs VA Medical Centers and multiple outpatient clinics in Nebraska, North Dakota, South Dakota, and Wyoming. 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 four recommendations for improvement in three areas:

1.    Medical staff privileging
•    Completion of Ongoing Professional Practice Evaluations
•    Review of Ongoing Professional Practice Evaluation data and documents

2.    Environment of care
•    Completion of environment of care inspections

3.    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
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs regularly complete Ongoing Professional Practice Evaluations for each licensed independent practitioner.

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

The Chief of Staff ensures the Executive Committee of the Medical Staff reviews Ongoing Professional Practice Evaluation data and documents its review prior to recommending licensed independent practitioners’ ongoing privileges to the Director.

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

The Director ensures staff complete environment of care inspections at the required frequency.

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

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation the same calendar day as a patient’s positive suicide risk screen in all ambulatory care settings.