Report Summary

The 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 Midwest district 3 zone 1 and four selected vet centers: Cleveland, Columbus, and Toledo in Ohio; and South Bend in Indiana. The OIG inspection focused on five review areas: leadership and organizational risks; quality reviews; suicide prevention; consultation, supervision, and training; and environment of care.

Generally, district leaders had a good understanding of quality improvement principles and implemented district-wide quality improvement programs in response to VA All Employee Survey results. District 3 zone 1 Vet Center Service Customer Feedback survey results were below the national average in all areas except satisfaction with overall quality of services at the vet center. The OIG issued one recommendation to the district director specific to annual in-service training; this recommendation was closed at the time of publication.

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

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 nine recommendations—seven specific to electronic client records and two for selected vet centers’ suicide prevention and intervention processes.

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

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