Report Summary

Title: Vet Center Inspection of Continental District 4 Zone 2 and Selected Vet Centers
Report Number: 20-04051-287 Download
Issue Date: 9/30/2021
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Vet Center Inspection Program
Release Type: Unrestricted

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. This report focuses on Continental district 4 zone 2 and four selected vet centers: Alexandria in Louisiana and Houston Southwest, Laredo, and Mesquite in Texas. The OIG inspection focused on six review areas: leadership and organizational risks; quality reviews; COVID-19 response; suicide prevention; consultation, supervision, and training; and environment of care.

Generally, district leaders were knowledgeable about quality improvement principles and implemented district-wide quality improvement programs in response to VA All Employee Survey results. District 4 zone 2 Vet Center Service Customer Feedback survey results exceeded national scores.

The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policy and procedures. The OIG made three recommendations for clinical and administrative quality reviews and two recommendations for critical incident quality reviews.

The COVID-19 response review showed district leaders adjusted and figured out what needed to be done to ensure vet centers remained operational. Employees’ response to an OIG questionnaire indicated district leaders and vet center directors were prepared and provided communication to ensure employee and client safety.

The suicide prevention review included a zone-wide evaluation of electronic client records, and a focused review of the four selected vet centers. The OIG issued eight recommendations—seven specific to electronic client records and one for selected vet centers’ suicide prevention and intervention processes.

The consultation, supervision, and training review evaluated the four selected vet centers, identified concerns with external clinical consultation, supervision, and training, and issued four recommendations.

The environment of care review evaluated the four selected vet centers and made three recommendations.

The OIG issued a total of 20 recommendations for improvement.