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Report File
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Components
Veterans Health Administration
Report Number
24-00615-163
Report Description

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the Sheridan VA Health Care System in Wyoming. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Primary care
     •    Veteran-centered safety net

The OIG issued three recommendations for improvement in two domains:
  1.    Environment of care
     •    Facility navigation tools for sensory-impaired veterans
  2.    Patient safety
     •    Patient test result communication effectiveness
     •    Service-specific workflows for test result communications

Report Type
Inspection / Evaluation
Agency Wide
Yes
Number of Recommendations
3
Questioned Costs
$0
Funds for Better Use
$0
Report updated under NDAA 5274
No

Open Recommendations

This report has 3 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
01 No $0 $0

The OIG recommends facility leaders implement tools to help sensory-impaired veterans navigate the facility.

02 No $0 $0

The OIG recommends facility leaders ensure the facility has a policy for test result communication that includes methods to monitor the effectiveness of the patient notification process.

03 No $0 $0

The OIG recommends facility leaders ensure staff develop workflows for the communication of test results for each service.

Department of Veterans Affairs OIG

United States