Healthcare Facility Inspection of the VA Battle Creek Healthcare System in Michigan

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Date Issued

Tuesday, February 3, 2026

Submitting OIG

Department of Veterans Affairs OIG

Agencies Reviewed/Investigated

Department of Veterans Affairs

Components

Veterans Health Administration

Report Number

25-00238-44

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 VA Battle Creek Healthcare System in Michigan.

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

The OIG issued four recommendations for VA to correct identified deficiencies in two domains:
1.    Environment of care
•    Clean and safe environment
•    Medical equipment maintenance
•    Repeat findings prevention
2.    Patient safety
•    Service-level workflows for test result communication

Report Type

Inspection / Evaluation

Location

Battle Creek, MI
United States

Number of Recommendations

Questioned Costs

Funds for Better Use

Report updated under NDAA 5274

External Link

https://www.vaoig.gov/reports/healthcare-facility-inspection/healthcare-facilit…

Open Recommendations

This report has 4 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
1	No	$0	$0
The Director ensures staff keep the environment clean and safe.
2	No	$0	$0
The Director ensures Healthcare Technology Management Service staff inspect, test, and properly document all medical equipment maintenance per their required schedule.
3	No	$0	$0
The Director ensures staff implement processes to prevent repeat environment of care findings identified in this report.
4	No	$0	$0
Facility leaders ensure service-level workflows include each staff members role in the communication of test results process.