This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Veterans Health Care System of the Ozarks, which includes the Fayetteville VA Medical Center and multiple outpatient clinics in Arkansas, Missouri, and Oklahoma. This evaluation focused on five key operational areas:
• Leadership and organizational risks
• Quality, safety, and value
• Medical staff privileging
• Environment of care
• Mental health (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. Medical Staff Privileging
• Service-specific criteria in Ongoing Professional Practice Evaluations
3. Environment of Care
• Contaminated, damaged, expired, or recalled medical supplies
• Notices in treatment areas subject to photography or video recording
4. Mental Health
• Safety plans for patients discharged from the Emergency Department with a positive suicide risk screen
Open
Closed-Implemented
Closed-Not ImplementedThe Director determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for applicable sentinel events.
The Chief of Staff determines the reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in Ongoing Professional Practice Evaluations.
The Director evaluates and determines any additional reasons for noncompliance and ensures staff maintain medical supplies that are not contaminated, damaged, expired, or recalled.
The Chief of Staff or Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff post notices in treatment areas with overt recording announcing the area is subject to photography or video recording.
The Director evaluates and determines the reasons for noncompliance and ensures staff create or update safety plans for patients with a positive suicide risk screen who are determined safe to discharge home from the Emergency Department.