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 Cincinnati Healthcare System in Ohio. This evaluation focused on five key content domains:
• Culture
• Environment of care
• Patient safety
• Primary care
• Veteran-centered safety net
The OIG issued nine recommendations for VA to correct identified deficiencies in two domains:
1. Environment of care
• Correct deficiencies found during comprehensive environment of care inspections
• Fire drills
• Medical equipment inspections and maintenance labels
• Clean patient care areas in the Emergency Department
• Exit pathways free from obstructions
2. Patient safety
• Service-level workflows for the communication of test results
• Monitoring providers’ communication of urgent, noncritical test results to patients
• Root cause analysis actions
• Patient safety program
Cincinnati, OH
United States
