Healthcare Facility Inspection of the VA St. Louis Healthcare System in Missouri

Report Information

Issue Date
Report Number
24-00600-136
VISN
15
State
Illinois
Missouri
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Patient Safety
Supplies and Equipment
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) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA St. Louis Healthcare System in Missouri. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Primary care
     •    Veteran-centered safety net

The OIG issued five recommendations for improvement in two domains:
   1.    Environment of care
     •    Supply storage locations and expired supplies
     •    Video laryngoscope supplies
     •    Safe and clean patient care areas
     •    Preventive maintenance for biomedical equipment
   2.    Patient safety
     •    Service-level workflows and processes to monitor patient test result communications

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 OIG recommends facility leaders determine appropriate supply storage locations, and for any supplies stored outside these defined locations, implement a process to ensure staff identify and remove expired supplies.

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

The OIG recommends facility leaders ensure video laryngoscope supplies are readily available and not expired.

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

The OIG recommends the Director ensures staff keep patient care areas clean and safe.

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

The OIG recommends the Director ensures staff complete required preventive maintenance for biomedical equipment.

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

The OIG recommends facility leaders develop service-level workflows and processes to monitor communication of test results to patients.