Comprehensive Healthcare Inspection of the White River Junction VA Medical Center in Vermont

Report Information

Issue Date
Report Number
23-00015-86
VISN
1
State
New Hampshire
Vermont
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
Major Management Challenges
Healthcare Services
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 White River Junction VA Medical Center and associated outpatient clinics in New Hampshire and Vermont. 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 five recommendations for improvement in three areas:

1.    Quality, safety, and value
•    Patient safety analyses

2.    Medical staff privileging
•    Focused Professional Practice Evaluations
•    Ongoing Professional Practice Evaluations

3.    Mental health
•    Suicide-related event reporting
•    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 Medical Center Director ensures staff complete a minimum of eight patient safety analyses each year.

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

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete Focused and Ongoing Professional Practice Evaluations.

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

The Chief of Staff ensures service chiefs complete licensed independent practitioners’ Ongoing Professional Practice Evaluations on a regular basis.

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

The Medical Center Director ensures the suicide prevention coordinators report suicide-related events monthly to mental health leaders and quality management staff.

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

The Medical Center 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.