Report Summary

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the VA Sierra Nevada Health Care System, which includes the Ioannis A. Lougaris VA Medical Center and multiple outpatient clinics in California and Nevada. 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 six recommendations for improvement in three areas:

1. Quality, Safety, and Value

• Peer review aspects of care

• Peer Review Committee improvement actions

2. Environment of Care

• Panic alarm testing documentation

• Patient safety cameras

• Minimizing risk of self-harm

3. Mental Health

• Patient follow-up