Comprehensive Healthcare Inspection of the W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina

Report Information

Issue Date
Report Number
23-00004-37
VISN
6
State
North Carolina
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 care provided at the W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina.

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 the mental health area of review:

•    Comprehensive Suicide Risk Evaluation

o    Completion following positive suicide screen

o    Suicide prevention team notified of suicidal or self-directed violent behaviors in previous 12 months

•    Full-time suicide prevention coordinator appointed for community-based outpatient clinics that serve 10,000 veterans annually

•    Suicide-related events reported monthly to mental health leaders and quality management staff

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 providers complete a Comprehensive Suicide Risk Evaluation following a positive suicide risk screen.

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

The Chief of Staff ensures clinical staff notify the suicide prevention team if patients report suicidal or other self-directed violent behaviors that occurred in the 12 months preceding the Comprehensive Suicide Risk Evaluation.

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

The Chief of Staff ensures leaders appoint one full-time suicide prevention coordinator to each community-based outpatient clinic that serves at least 10,000 unique veterans annually.

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

The Chief of Staff ensures the Suicide Prevention Program Manager reports suicide-related events monthly to mental health leaders and quality management staff.