This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the VA NY Harbor Healthcare System. The system includes three medical centers located in Brooklyn, Manhattan, and Queens and two outpatient clinics in New York. 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 suicide prevention initiatives)
The OIG issued 12 recommendations for improvement in four areas:
1. Quality, safety, and value
• Peer review aspects of care
• Peer Review Committee recommendations
• Communication and implementation of recommendations
2. Medical staff privileging
• Service-specific criteria in professional practice evaluations
3. Environment of care
• Inspections
• Deficiency monitoring until resolution
• Over-the-door alarm testing
• Hazard warning signs
• Safety and cleanliness
4. Mental health
• Suicide-related events reporting
• Comprehensive Suicide Risk Evaluations
• Notification of suicidal behaviors
The report can be found online here.
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