Healthcare Facility Inspection of the Eastern Oklahoma VA Health Care System in Muskogee

Report Information

Issue Date
Report Number
25-00194-239
VISN
19
State
Oklahoma
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Patient Care Services Operations
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
3
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 Eastern Oklahoma VA Health Care System in Muskogee. This evaluation focused on five key content domains:
•    Culture
•    Environment of care
•    Patient safety
•    Primary care
•    Veteran-centered safety net

The OIG issued three recommendations for VA to correct identified deficiencies in two domains:
1.    Environment of care
•    Clean and safe environment
2.    Patient safety
•    Service-level workflows for test result communication
•    Effectiveness of the patient notification process

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)

Facility leaders ensure staff follow facility policies and maintain a cleanenvironment.

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

Facility leaders ensure staff develop service-level workflows for the communication of urgent, noncritical test results.

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

Executive leaders monitor the effectiveness of the patient notification process.