Comprehensive Healthcare Inspection of the VA North Texas Health Care System in Dallas

Report Information

Issue Date
Report Number
22-00038-125
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
Suicide Prevention
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
2
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 VA North Texas Health Care System, which includes the Dallas VA Medical Center, Garland VA Medical Center, Sam Rayburn Memorial Veterans Center (Bonham), 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 two recommendations for improvement in two areas: 1. Leadership and organizational risks • Institutional disclosures 2. Mental health • Follow-up for patients at risk for 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 Executive Director evaluates and determines additional reasons for noncompliance and ensures leaders conduct and accurately document institutional disclosures for applicable sentinel events.

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

The Assistant Director Clinical Services evaluates and determines any additional reasons for noncompliance and ensures mental health staff attempt weekly follow-up until care is established for patients discharged from the emergency department who are at intermediate or high acute or chronic risk of suicide.