Comprehensive Healthcare Inspection Summary Report: Evaluation of Leadership and Organizational Risks in Veterans Health Administration Facilities, Fiscal Year 2020

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a descriptive evaluation of Veterans Health Administration facilities’ leadership and organizational risks. The report focuses on executive leadership position stability and engagement, accreditation surveys and oversight inspections, factors related to possible lapses in care, and Veterans Health Administration performance data. This report describes observations from healthcare inspections performed at 36 VHA medical facilities from November 4, 2019, through September 21, 2020. Each inspection involved interviews with facility leaders and staff and reviews of administrative processes. The OIG reviewers evaluated meeting minutes and other relevant documents. The results in this report are a snapshot of VHA performance at the time of the fiscal year 2020 OIG reviews. The OIG found that leaders were generally knowledgeable about their facilities and various performance metrics and could speak to actions taken to improve their respective facility’s performance. The OIG observed that lower complexity facilities had fewer reported sentinel events than higher complexity facilities.