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Comprehensive Healthcare Inspection Summary Report: Evaluation of Women's Health Care in Veterans Health Administration Facilities, Fiscal Year 2020

Report Information

Issue Date
Report Number
21-01508-32
VISN
State
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
National Healthcare Review
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
4
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of Veterans Health Administration facilities’ selected Women’s Health (WH) program requirements. This evaluation focused on provision of care requirements, oversight of program and monitoring of performance improvement data, and assignment of required staff. This report describes WH-related findings from healthcare inspections initiated at 36 Veterans Health Administration medical facilities from November 4, 2019, through September 21, 2020. Each inspection involved interviews with facility leaders and staff and reviews of clinical and administrative processes. The OIG reviewers evaluated meeting minutes and other relevant documents. The results in this report are a snapshot of Veterans Health Administration performance at the time of the fiscal year 2020 OIG reviews. The OIG found general compliance with many of the selected requirements. However, the OIG identified weaknesses with: • provision of 24/7 gynecologic care coverage, • assignment of at least two women’s health primary care providers for each community-based outpatient clinic, • women veterans health committee core members and reporting to clinical executive leaders, • assignment of a full-time women veterans program manager who is free of collateral duties, and • designation of maternity care coordinators.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that each facility has processes and procedures in place for emergency care 24 hours per day, 7 days per week and facility call coverage for gynecologic care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that each facility has a women veterans program manager who is full-time and free of collateral duties.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that each facility has a designated maternity care coordinator.