Comprehensive Healthcare Inspection of the VA Greater Los Angeles Healthcare System in California

Report Information

Issue Date
Report Number
22-00055-184
VISN
1
State
California
District
Continental
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
9
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 Greater Los Angeles Healthcare System, which includes the West Los Angeles VA Medical Center and multiple outpatient clinics throughout California. This evaluation focused on five key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care • Mental health (focusing on emergency department and urgent care center suicide prevention initiatives) The OIG issued nine recommendations for improvement in three areas: 1. Quality, Safety, and Value • Peer review improvement actions • Patient safety event root cause analysis 2. Medical Staff Privileging • Focused Professional Practice Evaluation time frames • Ongoing Professional Practice Evaluation service-specific criteria • Privileging request recommendations in Medical Executive Council meeting minutes 3. Environment of Care • Inspecting, testing, and maintaining medical equipment • Maintaining equipment and furnishings and keeping patient care areas clean and safe • Using breathable shower curtains in mental health inpatient unit bathrooms • Recording and accessing video or audio monitoring equipment

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
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to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
No. 2
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to Veterans Health Administration (VHA)
The Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines reasons for noncompliance and ensures section or service chiefs define time frames for Focused Professional Practice Evaluations.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff determines the reasons for noncompliance and ensures service chiefs include service-specific criteria in Ongoing Professional Practice Evaluations.
No. 5
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to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures Medical Executive Council meeting minutes consistently contain its recommendations for privileging requests
No. 6
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to Veterans Health Administration (VHA)
The Associate Director, Operations evaluates and determines any additional reasons for noncompliance and ensures staff inspect, test, and maintain all medical equipment.
No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Director evaluates and determines any additional reasons for noncompliance and ensures staff maintain equipment and furnishings in good working order and keep areas used by patients clean, safe, and suitable for care.
No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Director evaluates and determines reasons for noncompliance and ensures that only breathable shower curtains are present in mental health inpatient unit bathrooms.
No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff or Associate Director, Patient Care Service/Nurse Executive determines the reasons for noncompliance and ensures video or audio monitoring equipment installed for patient safety purposes does not record and is only accessed and viewed by Veterans Affairs healthcare providers.