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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
Components
Veterans Health Administration
Report Number
21-00235-13
Report Description

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 1: VA New England Healthcare System in Bedford, Massachusetts, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection also focused on COVID-19: Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Mental Health: Suicide Prevention; Care Coordination: Inter-facility Transfers; and Women’s Health: Comprehensive Care.Most of the VISN’s executive leadership team had worked together since 2018; however, the Chief Medical Officer had served in an acting capacity since October 2020. Employee satisfaction survey scores indicated that leaders were engaged and promoted a culture of safety where employees felt safe bringing forward issues and concerns. Patient experience survey scores were higher than VHA averages. The OIG’s review of access metrics and clinical vacancies identified potential organizational risks at select facilities, with wait times over 20 days and clinical vacancies in certain specialties.The OIG issued five recommendations for improvement in three areas:(1) Medical Staff Credentialing• Physician credentials file review and appointment approval(2) Mental Health• Designated mental health professional to serve on state suicideprevention council or workgroup(3) Women’s Health• Quarterly program updates to VISN leaders• Staff education gap assessments and development of educational material• VISN-level support staff availability

Report Type
Review
Location

Leeds, MA
United States

Boston, MA
United States

Augusta, ME
United States

Bedford, MA
United States

Manchester, NH
United States

Providence, RI
United States

West Haven, CT
United States

White River Junction, VT
United States

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

Department of Veterans Affairs OIG

United States