Report Summary

This report is the result of an Office of Inspector General (OIG) inspection of the VA Medical Center in Washington, D.C., (DC VAMC) that began in March 2017 after receiving a confidential complaint. The OIG released an interim report on April 12, 2017, identifying risks to patients and VA assets. This final report provided findings in four areas: (1) risk of harm to patients, (2) hospital service deficiencies affecting patient care, (3) lack of financial controls, and 4) failures in leadership.

The OIG found that critical deficiencies at the DC VAMC were pervasive and persistent—often spanning many years—but were not successfully remediated by leaders at multiple levels within VA. These deficiencies impacted core medical center functions that healthcare providers need to effectively provide quality care. The report details the DC VAMC’s failures in ensuring supplies and equipment reached patient care areas when needed, processing and sterilizing instruments, managing and securing assets, maintaining cleanliness, providing timely prosthetic devices, properly reporting and analyzing patient safety events, and receiving the staffing and leadership needed for sustainable change. The OIG did not find evidence of adverse clinical outcomes, a condition that is largely attributable to front-line care providers who were committed to providing the best possible care by borrowing supplies, improvising, or personally ensuring patients received what they needed. The OIG made 40 recommendations and VA concurred with each one. VA also provided detailed action plans on how the recommendations are going to be implemented and identified the progress they have already made. This report is meant to not only improve conditions at the DC VAMC, but also to serve as a roadmap for other VA medical facilities and to improve integrated reviews and oversight by Veterans Integrated Service Networks and VA central offices.