Comprehensive Healthcare Inspection of the VA Salt Lake City Health Care System in Utah

Report Information

Issue Date
Report Number
23-00013-128
VISN
19
State
Idaho
Nevada
Utah
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
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
6
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 Salt Lake City Health Care System, which includes the George E. Wahlen VA Medical Center in Salt Lake City and multiple outpatient clinics in Idaho, Nevada, and Utah. 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 six recommendations for improvement in three areas:
1.    Medical staff privileging
•    Focused Professional Practice Evaluation results

2.    Environment of care
•    Environment of care inspections
•    Inpatient Psychiatry Unit:
    •    Panic and over-the-door alarm testing
    •    Maintaining a safe environment

3.    Mental health
•    Comprehensive Suicide Risk Evaluation completion
 

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 report Focused Professional Practice Evaluation results to an executive committee of the medical staff for consideration in privileging recommendations.

No. 2
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to Veterans Health Administration (VHA)

The Director ensures staff conduct environment of care inspections in patient care areas as required.

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

The Director ensures staff test panic alarms in the Inpatient Psychiatry Unit at least quarterly and record testing in a log, including police response times.

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

The Director ensures staff test over-the-door alarms in the Inpatient Psychiatry Unit per the manufacturer’s recommendations.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff keep interior spaces in the Inpatient Psychiatry Unit safe and suitable for care.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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