Comprehensive Healthcare Inspection of the South Texas Veterans Health Care System in San Antonio

Report Information

Issue Date
Report Number
22-00040-115
VISN
17
State
Texas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Patient Safety
Suicide Prevention
Medical Staff Privileging Credentialing
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

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

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director determines the reasons for noncompliance and ensures leaders evaluate adverse events and conduct institutional disclosures when criteria are met.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs consider service-specific Ongoing Professional Practice Evaluation data when recommending licensed independent practitioners’ continued privileges.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct follow-up within one week for intermediate, high-acute, or chronic risk-for-suicide patients who were discharged home from the emergency department.