Combined Assessment Program Review of the VA Palo Alto Health Care System, Palo Alto, California

The purpose of the review was to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 389 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) coordination of care – hospice and palliative care, (2) long-term home oxygen therapy, and (3) medication management – controlled substances inspections. The facility’s reported accomplishments were a performance excellence award, a patient safety culture collaborative, and an extensive research program. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) environment of care, (3) nurse staffing, and (4) preventable pulmonary embolism.