Healthcare Facility Inspection of the VA Detroit Healthcare System in Michigan

Report Information

Issue Date
Report Number
24-00607-241
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
6
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 Detroit 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 six recommendations for VA to correct identified deficiencies in one domain:
1.    Environment of care
•    Damaged furnishings
•    Maps for navigation
•    Clean equipment storage
•    Unobstructed hallways and exits
•    Defective equipment removal
•    Computer screen privacy filters

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)

Executive leaders ensure staff fix or replace damaged furnishings to allow effective cleaning and disinfection.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/14/2025

Executive leaders ensure staff place paper maps at information desks to assist veterans in navigating the facility.

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

Executive leaders ensure staff store clean equipment in a sanitary environment.

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

Executive leaders ensure hallways and exits are free from obstruction.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Executive leaders ensure staff remove defective equipment from clinical areas to prevent use.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Executive leaders ensure staff have computer screen privacy filters to protect patients’ personally identifiable information.