This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Butler VA Health Care System, which includes the Butler VA Medical Center, Abie Abraham VA Clinic, and multiple outpatient clinics in Pennsylvania. This evaluation focused on four key operational areas:
• Leadership and organizational risks
• Quality, safety, and value
• Medical staff privileging
• Environment of care
The OIG issued two recommendations for improvement in two areas:
1. Quality, Safety, and Value
• Root cause analysis for patient safety events
2. Environment of Care
• Clean and safe environment
The report can be found online here.