Report Summary

Title: Vet Center Inspection of Pacific District 5 Zone 1 and Selected Vet Centers
Report Number: 21-01805-286 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 Pacific district 5 zone 1 and four selected vet centers—Bellingham and Tacoma in Washington, Central Oregon in Bend, and Wasilla in Alaska. 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.

Overall, district leaders had a good understanding about quality improvement principles and implemented district-wide quality improvement programs in response to VA All Employee Survey results. District 5 zone 1 Vet Center Service Customer Feedback survey results were favorable in five of six areas.

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 one recommendation for critical incident quality reviews.

The COVID-19 response review showed district leaders were as prepared as possible and able to enact emergency plan procedures to ensure vet centers remained operational. Employees’ response to an OIG questionnaire reflected that communication from district leaders and vet center directors was adequate to ensure the safety of clients and staff.

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 11 recommendations addressing eight zone-wide and three selected vet centers’ suicide prevention and intervention processes.

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

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

The OIG issued 23 recommendations for improvement.