Report Summary

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of care delivered at vet centers. This report focused on North Atlantic district 1 zone 4 and four selected vet centers: Baltimore and Dundalk in Maryland, Raleigh in North Carolina, and Richmond in Virginia. 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 1 zone 4 Vet Center Service Customer Feedback survey results were below the national average in all areas except one regarding vet center location. High turnover and use of technology instead of face-to-face visits were noted as reasons.

The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policies and procedures. The OIG made five recommendations for clinical and administrative quality reviews and issued one finding 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 ten recommendations—six related to the review of electronic client records and four specific to the 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, chart audits and training, and issued four recommendations.

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

The OIG issued a total of 22 recommendations for improvement to the District Director.