Comprehensive Healthcare Inspection of the Overton Brooks VA Medical Center in Shreveport, Louisiana

Submitting OIG:

Report Description:

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 Overton Brooks VA Medical Center and multiple outpatient clinics in Arkansas, Louisiana, and 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 15 recommendations for improvement in three areas: 1. Medical Staff Privileging • Focused Professional Practice Evaluation completion • Equivalent specialized training and similar privileges • Service-specific criteria • Privileging and reprivileging recommendations 2. Environment of Care • Inspection frequency • Naloxone in Automated External Defibrillator cabinets • Expired supplies • Clean floors • Safe and functional environment • Furnishings safe and in good repair • Damaged walls • Stained ceiling tiles • Signage in areas with recording equipment 3. Mental Health • Assessment of lethality of most recent suicide attempt

Date Issued:

Wednesday, November 15, 2023

Agency Reviewed / Investigated:

Department of Veterans Affairs

Submitting OIG-Specific Report Number:

22-00240-17

Component, if applicable:

Veterans Health Administration

Location(s):

Shreveport, LA

United States

Type of Report:

Review

Questioned Costs:

Funds for Better Use:

Number of Recommendations:

Report updated under NDAA 5274:

View Document:

Attachment	Size
vaoig-22-00240-17.pdf	3.74 MB

Additional Details Link:

https://www.vaoig.gov/reports/comprehensive-healthcare-inspection-program/compre…

Recommendation Number	Recommendation Status	Significant Recommendation
01	Open	No
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs complete Focused Professional Practice Evaluations for all licensed independent practitioners.
02	Open	No
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete licensed independent practitioners’ professional practice evaluations.
03	Open	No
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in licensed independent practitioners’ professional practice evaluations.
04	Open	No
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs consider relevant Ongoing Professional Practice Evaluation data in reprivileging recommendations.
05	Open	No
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board uses professional practice evaluation results to recommend privileges for licensed independent practitioners.
08	Open	No
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff check inventory in clean storerooms and remove expired supplies in the Emergency Department and medical/surgical inpatient unit.
13	Open	No
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff replace stained ceiling tiles in the Emergency Department and Primary Care Red Team.
15	Open	No
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers assess whether patients’ most recent suicide attempt was their most lethal when completing the Comprehensive Suicide Risk Evaluation.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

Open

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs complete Focused Professional Practice Evaluations for all licensed independent practitioners.

Open

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete licensed independent practitioners’ professional practice evaluations.

Open

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in licensed independent practitioners’ professional practice evaluations.

Open

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs consider relevant Ongoing Professional Practice Evaluation data in reprivileging recommendations.