Report Summary

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 2 and four selected vet centers—Fresno, High Desert, and Santa Cruz County in California; and Honolulu, Hawaii. 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 healthcare quality improvement and shared actions taken during the past 12 months in response to VA All Employee Survey results. District 5 zone 2 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 and made four recommendations for clinical and administrative quality reviews.

The COVID-19 response review showed that supplies were adequate and safety practices, including wearing of masks and practicing safe social distancing, were used throughout the zone. Overall, employees’ responses indicated 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 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 four recommendations.

The environment of care review evaluated the four vet centers. The OIG made one recommendation.

The OIG issued a total of 17 recommendations for improvement to the District Director.