Healthcare Facility Inspection of the San Francisco VA Health Care System in California

Report Information

Issue Date
Report Number
26-00032-248
VISN
5
State
California
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Healthcare Infrastructure
Maintenance and Construction
Patient Care Services Operations
Patient Safety
Staffing
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 San Francisco VA Health Care System in California.

This evaluation focused on five key domains: 
     •    Culture 
     •    Environment of care 
     •    Patient safety 
     •    Integrated veteran care 
     •    Veteran-centered safety net

The OIG made four recommendations for VA to correct identified issues in three domains: 
     •    Environment of care 
       o    Fire doors closing properly 
     •    Patient safety 
       o    Updated policy for test result communications 
       o    Service-level workflows for test result communications
     •    Integrated veteran care 
       o    Patient Centered Management Module data
 

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2026

The Director takes appropriate actions so fire doors close completely and latch, as required by National Fire Protection Association 80 Standard for Fire Doors and Other Opening Protectives.

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

The Director takes appropriate actions so staff update the facility policy on test result communications to meet the requirements of Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

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

The Chief of Staff and Associate Director for Patient Care Services/Nurse Executive take appropriate actions so staff develop, for each service, written workflows consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2026

The Director takes appropriate actions for the Chief of Staff to review Patient Centered Management Module data and address efficiency, capacity, and staffing needs, in accordance with Veterans Health Administration Directive 1406(3), Patient Centered Management Module (PCMM) for Primary Care.