Healthcare Facility Inspection of the VA Pacific Islands Health Care System in Honolulu, Hawaii

Report Information

Issue Date
Closure Date
Report Number
25-04253-243
VISN
5
State
Hawaii
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Patient Care Services Operations
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
1
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Pacific Islands Health Care System in Honolulu, Hawaii.

This evaluation focused on five key domains: 
     •    Culture 
     •    Environment of care 
     •    Patient safety 
     •    Integrated veteran care 
     •    Veteran-centered safety net

The OIG made one recommendation for VA to correct identified issues in one domain: 
     •    Patient safety 
       o    Service-level workflows for test result communications
 

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)
Closure Date: 8/14/2026

The Chief of Staff and Associate Director for Patient Care Services develop workflows that describe how each team member participates in the process for communicating test results.