Comprehensive Healthcare Inspection of the VA Northern California Health Care System in Mather

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 Northern California Health Care System, which includes the Sacramento VA Medical Center, Martinez VA Medical Center, an outpatient clinic at Travis Air Force Base, and other outpatient clinics in 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 (emergency department and urgent care center suicide prevention initiatives) The OIG issued seven recommendations for improvement in three areas: 1. Medical Staff Privileging • Evaluation result documentation and reporting • Reprivileging recommendations based on service-specific Ongoing Professional Practice Evaluation data 2. Environment of Care • Panic and over-the-door alarm testing in the inpatient mental health unit • Cleanliness, furnishings, and equipment • Properly stored and secured medications 3. Mental Health • Timely follow-up for patients at risk for suicide discharged from the Emergency Department