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Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021.

Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03.

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November 16, 2022

Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03.

Organizational evaluations often reveal opportunities to address persistent quality and safety issues. This extensive inspection report shares findings from examinations at 45 Veterans Health Administration care facilities that focused on assessing oversight, system redesign and surgical programs. Recommendations drawn from the analysis call for improvements in protected peer review, surgical work structure and surgical adverse incident examination.

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Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03.

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