Report Summary

Title: Vet Center Inspection of Continental District 4 Zone 1 and Selected Vet Centers
Report Number: 20-04050-37 Download
Issue Date: 12/2/2021
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 1 and four selected vet centers: Casper, Wyoming; Denver, Colorado; and El Paso and Midland in Texas. The 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 engaged in continuous improvement activities in response to VA All Employee Survey results. District 4 zone 1 Vet Center Service Customer Feedback survey results exceeded national scores in four of the six categories.

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 that while initially there were personal protective equipment shortages for staff, adequate supplies were reported at the time of inspection. Employees’ responses indicated that district leaders and vet center directors provided communication and guidance that helped with employee and client safety.

The suicide prevention review included a zone-wide evaluation of electronic client records, and a focused review of 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 vet centers. The OIG identified concerns with external clinical consultation, supervision, and training, and issued five recommendations.

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

The OIG issued a total of 20 recommendations for improvement to the District Director.