Healthcare Facility Inspection of the VA Battle Creek Healthcare System in Michigan

Report Information

Issue Date
Closure Date
Report Number
25-00238-44
VISN
10
State
Michigan
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
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 Battle Creek Healthcare System in Michigan. 

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
     •    Clean and safe environment
     •    Medical equipment maintenance
     •    Repeat findings prevention
   2.    Patient safety
     •    Service-level workflows for test result communication

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: 2/3/2026

The Director ensures staff keep the environment clean and safe.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2026

The Director ensures Healthcare Technology Management Service staff inspect, test, and properly document all medical equipment maintenance per their required schedule.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2026

The Director ensures staff implement processes to prevent repeat environment of care findings identified in this report.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2026

Facility leaders ensure service-level workflows include each staff member’s role in the communication of test results process.