Comprehensive Healthcare Inspection of the Butler VA Health Care System in Pennsylvania

Report Information

Issue Date
Report Number
22-00068-171
VISN
1
State
Pennsylvania
District
Continental
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
2
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Butler VA Health Care System, which includes the Butler VA Medical Center, Abie Abraham VA Clinic, and multiple outpatient clinics in Pennsylvania. This evaluation focused on four key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care The OIG issued two recommendations for improvement in two areas: 1. Quality, Safety, and Value • Root cause analysis for patient safety events 2. Environment of Care • Clean and safe environment

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 Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager initiates an individual root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Executive Director determines any additional reasons for noncompliance and ensures leaders maintain a clean and safe environment.