OIG issues 11 Recommendations for Improvement to Roseburg VA Health Care

US Dept. of Veterans Affairs
Office of Inspector General

This Office of Inspector General (OIG) recently concluded a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Roseburg VA Health Care System, which includes the Roseburg VA Medical Center and multiple outpatient clinics in Oregon.

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 11 recommendations for improvement in four areas:
1. Leadership and organizational risks
• Root cause analyses for sentinel events
2. Medical staff privileging
• Focused and Ongoing Professional Practice Evaluation completion
• Ongoing Professional Practice Evaluations
o Specialty-specific data
o Equivalent specialized training and similar privileges
• Executive committee review of professional practice evaluation results
• VISN oversight of privileging processes
3. Environment of care
• Panic and over-the-door alarm testing in the mental health inpatient unit
4. Mental health
• Comprehensive Suicide Risk Evaluation completion
• Reporting of suicide behaviors to suicide prevention team
• Suicide prevention outreach activities

To download a copy of the full report, click on the following link: https://tinyurl.com/4ax9tb2e