Report Summary

Title: Comprehensive Healthcare Inspection of Veterans Integrated Service Network 1: VA New England Healthcare System in Bedford, Massachusetts
Report Number: 21-00235-13 Download
Issue Date: 11/18/2021
City/State: Bedford, MA
Leeds, MA
West Haven, CT
Augusta, ME
White River Junction, VT
Manchester, NH
Providence, RI
Boston, MA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 1: VA New England Healthcare System in Bedford, Massachusetts, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection also focused on COVID-19: Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Mental Health: Suicide Prevention; Care Coordination: Inter-facility Transfers; and Women’s Health: Comprehensive Care.

Most of the VISN’s executive leadership team had worked together since 2018; however, the Chief Medical Officer had served in an acting capacity since October 2020. Employee satisfaction survey scores indicated that leaders were engaged and promoted a culture of safety where employees felt safe bringing forward issues and concerns. Patient experience survey scores were higher than VHA averages. The OIG’s review of access metrics and clinical vacancies identified potential organizational risks at select facilities, with wait times over 20 days and clinical vacancies in certain specialties.

The OIG issued five recommendations for improvement in three areas:

(1) Medical Staff Credentialing

• Physician credentials file review and appointment approval

(2) Mental Health

• Designated mental health professional to serve on state suicide

prevention council or workgroup

(3) Women’s Health

• Quarterly program updates to VISN leaders

• Staff education gap assessments and development of educational material

• VISN-level support staff availability