Report Summary

This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the South Texas Veterans Health Care System, which includes the Audie L. Murphy Memorial Veterans’ Hospital in San Antonio, the Kerrville VA Medical Center, and multiple outpatient clinics in Texas. This evaluation focused on five key operational areas:

• Leadership and organizational risks

• Quality, safety, and value

• Medical staff privileging

• Environment of care

• Mental health (emergency department and urgent care center suicide prevention initiatives)

The OIG issued three recommendations for improvement in three areas:

1. Leadership and organizational risks

• Adverse event evaluation and institutional disclosures

2. Medical staff privileging

• Reprivileging decisions

3. Mental health

• Follow-up for patients at risk of suicide