Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Networks 10 and 20

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 10 and 20 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; and facility staff feedback. The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt dissemination of information given the quickly changing landscape as infection rates and demands on facilities continually shift. Findings of inspected medical facilities are grouped by VISN, which are regional offices that provide oversight of medical centers in their area. This report, the first in a series, describes findings on COVID-19 practices from healthcare inspections performed within VISNs 10 and 20 from July 1 through September 30, 2020. It also provides a more recent snapshot of the pandemic’s demands on these facilities’ operations based on data compiled as of December 31, 2020. Interviews and survey results provide additional context on lessons learned and perceptions of both preparedness and response. This report also provides data that illustrates the tremendous COVID-19-related demands on VA healthcare services. It describes leader and staff experiences, assessments, shared sentiments, and best practices to help improve operations and clinical care during public health crises. At the time of the inspections, the Veterans Health Administration and the VISNs had not yet experienced the full force of the pandemic peaks in November and December 2020 but had valuable information to share about their experiences to date.