Federal Reports

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Augusta Health Care System in Georgia. This evaluation focused on five key content domains:
•    Culture
•    Environment of care
•    Patient safety
•    Primary care
•    Veteran-centered safety net
The OIG issued five recommendations for improvement in three domains:
1.    Culture
•    The Under Secretary for Health evaluates facility leaders for appropriate supervisory behavior and professional communication, and takes actions as needed.
•    The Under Secretary for Health determines whether the Veterans Integrated Service Network Director and other leaders were aware of facility leaders’ unprofessional behavior and communication, and takes actions as needed.
2.    Environment of care
•    The Under Secretary for Health ensures the Veterans Integrated Service Network and facility directors oversee the inventory management system and resolve medical supply deficiencies, and monitor actions for sustained improvement.
3.    Patient Safety
•    Facility leaders develop action plans to ensure providers communicate test results to patients timely.
•    The Under Secretary for Health directs the national VHA Quality and Patient Safety Program staff to review the facility’s quality management program and determine whether actions by facility and Veterans Integrated Service Network leaders effectively addressed system issues affecting patient safety, including nursing leaders’ lack of access to safety reports, and missed opportunities for institutional disclosures, and takes action as needed.