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Report File
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Other Participating OIGs
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Report Number
23-00101-137
Report Description

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Bedford Healthcare System, which includes the Edith Nourse Rogers Memorial Veterans’ Hospital in Bedford and three outpatient clinics in Massachusetts. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued five recommendations for improvement in four areas:1. Leadership and organizational risks• Institutional disclosures for applicable sentinel events2. Quality, safety, and value• Root cause analysis for patient safety events3. Environment of care• Patient care areas clean and free from undue wear• Inpatient mental health unit over-the-door alarm testing4. Mental health• Comprehensive Suicide Risk Evaluation completion

Report Type
Inspection / Evaluation
Location

Bedford, MA
United States

Number of Recommendations
2
Questioned Costs
$0
Funds for Better Use
$0

Department of Veterans Affairs OIG

United States