Report Summary

Title: Comprehensive Healthcare Inspection of Veterans Integrated Service Network 2: New York/New Jersey VA Health Care Network in Bronx, New York
Report Number: 21-00240-158 Download
Issue Date: 5/31/2022
City/State: Bronx, NY
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) 2: New York/New Jersey VA Health Care Network in Bronx, New York, 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.

The VISN had a stable leadership team, with the Quality Management Officer and Chief, Human Resources Officer permanently assigned prior to the integration of VISNs 2 and 3 in 2015. Selected employee satisfaction survey scores indicated that some VISN leaders had opportunities to improve employee perceptions of servant leadership, respect, discrimination, and psychological safety. Inpatient experience survey scores were lower than VHA national averages but outpatient ratings were higher. The OIG’s review of access metrics and clinical vacancies identified potential organizational risks, with wait times over 20 days at one medical center and clinical vacancies in certain specialties. Opportunities existed to improve executive leadership oversight of facility-level oversight of quality, safety, and value; care coordination; and high-risk processes.

The OIG issued four recommendations for improvement in three areas:

(1) Medical Staff Credentialing

• Physician credentials review process

(2) Environment of Care

• Annual reviews

(3) Women’s Health

• Lead women veterans program manager appointment

• Annual site visits