Healthcare Facility Inspection of the VA Connecticut Healthcare System in West Haven

Report Information

Issue Date
Report Number
24-00610-164
VISN
1
State
Connecticut
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Maintenance and Construction
Patient Care Services Operations
Patient Safety
Supplies and Equipment
Major Management Challenges
Healthcare Services
Recommendations
4
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

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 Connecticut Healthcare System in West Haven. 

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 improvement in three domains:
  1.    Culture
     •    Unanswered phone calls from veterans
  2.    Environment of care
     •    Performance improvement plans and outcome measures for environment of care trends
     •    Preventive maintenance for beds and stretchers
  3.    Primary care
     •    Veterans Integrated Service Network call center
 

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The OIG recommends facility leaders develop and implement a plan to address veterans’ unanswered phone calls.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The OIG recommends the Associate Director ensures staff identify environment of care trends and establish performance improvement plans with outcome measures to address them.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The OIG recommends the Associate Director ensures the manufacturer satisfies contractual requirements to perform preventive maintenance for beds and stretchers and documents the service.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The OIG recommends the Veterans Integrated Service Network Director works with facility and primary care leaders to address the network call center’s effect on primary care team efficiency and workload and reduce the risk of adverse patient safety events.