Healthcare Facility Inspection of the VA Palo Alto Health Care System in California

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 Palo Alto Health Care System in California. 

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
     •    Staff access to shared bathrooms
     •    Keeping exterior doors closed
     •    Separate clean and dirty storage
   2.    Patient safety
     •    Service-level workflows for test result communication