Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a review at the Ioannis A. Lougaris VA Medical Center in Reno, Nevada. The review proactively identified and evaluated declining performance metrics that could affect quality of care and patient safety. The OIG selected the facility because...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Illiana Health Care System and multiple outpatient clinics in Illinois. The inspection covers...

The VA Office of Inspector General (OIG) conducted an inspection to evaluate facility oversight and leaders’ response to a pathologist’s practice at the facility. The OIG found the Pathology and Laboratory Medicine Chief (Chief) followed VHA policy and performed a quality review of surgical...

The VA Office of Inspector General (OIG) conducted an inspection at the Washington DC VA Medical Center (facility) to assess care provided to a patient six days prior to death by suicide and an allegation that an Emergency Department physician made a statement to the effect of “[the patient] can go...

The VA Office of Inspector General (OIG) investigated a non-specific allegation that chief nurses within the Miami VA Health Care System (Miami HCS) violated the federal anti-nepotism statute by arranging to have their spouses hired for positions for which the spouses were not qualified. This...

The Office of Special Reviews investigated allegations that a GS-14 employee in VA’s Office of Information and Technology misused his government email by sending personal emails during work hours, and also took advantage of his telework arrangement to handle personal matters during his duty hours...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Kansas City VA Medical Center and multiple outpatient clinics in Kansas and Missouri. The...

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Nashville VA Medical Center in Tennessee to evaluate alleged deficiencies in cardiac telemetry monitoring services including policies, staffing, and communication. The OIG did not substantiate • The system’s policy...

Quality review team (QRT) program specialists oversee employees in the Veterans Benefits Administration (VBA) who process disability compensation claims. The VA Office of Inspector General (OIG) examined whether QRT specialists conducted accurate quality reviews; regional office managers decided...

The VA Office of Inspector General (OIG) reviewed the Systematic Technical Accuracy Review (STAR) program, which helps the Veterans Benefits Administration (VBA) provide timely and accurate disability compensation benefits to veterans and their beneficiaries. VBA’s STAR analysts perform quality...