Federal Reports

In response to a congressional request, the VA Office of Inspector General (OIG) inspected the John D. Dingell VA Medical Center in Detroit, Michigan (facility) to assess leaders’ progress toward implementation of recommendations from the VHA Office of the Medical Inspector (OMI). The OIG evaluated facility leaders’ actions related to High Reliability Organization (HRO) goals and Veterans Integrated Service Network (VISN) 10 leaders’ oversight of, and support provided to, the facility leaders.The OIG found concerns related to VISN and facility leaders’ corrective actions in response to 6 of the 10 OMI recommendations. (1) Facility leaders did not meet VHA requirements related to the supervision of post-graduate year -1 residents. (2) Facility leaders delayed taking a privileging action and missed opportunities for state licensing board (SLB) reporting. (3) The interim chief of surgery’s facilitation of morbidity and mortality (M&M) conferences was inconsistent. (4) The facility corrective action plan was deficient for the OMI recommendation regarding the reassessment of a Peer Review Committee member. (5) The VISN academic affiliations officer was not made aware of the OMI recommendation related to resident supervision, did not provide oversight to the facility’s surgical residency program, and did not ensure compliance with VHA policy. (6) The VISN surgical workgroup did not document vital information from the facility, which could have ramifications across other VISN facilities.The OIG identified additional concerns regarding stable and continuous leadership in the facility, the impact of leaders’ actions on HRO principles, and VISN oversight of, and support to, facility leaders. The OIG made four recommendations to VISN leaders and five recommendations to facility leaders. Recommendations addressed resident supervision, National Surgery Office review, National Practitioner Data Bank and SLB reporting, M&M conferences, VISN academic affiliations officer roles and responsibilities, VISN surgical workgroup, VISN oversight and support to the facility, and continued efforts towards HRO.

We summarized (1) direct payments SSA made to claimant representatives during Calendar Years 2018 through 2022, and (2) user fees SSA charged claimant representatives to process the direct payments during Fiscal Years 2018 through 2022

An Amtrak Assistant Passenger Conductor based in Denver, Colorado, was terminated from employment on May 25, 2023, following his administrative hearing. The Denver Police Department requested our assistance in identifying an individual who was suspected of shoplifting items valued at $244 from a Whole Foods Market while wearing an Amtrak uniform. Our investigation resulted in the identification of the former employee and he, subsequently, pleaded guilty to and was convicted for shoplifting.

The EPA needs to shift its focus from point sources to nonpoint sources to achieve the necessary Chesapeake Bay TMDL pollutant reduction goals.

Our objective was to identify any challenges with company systems and processes that could impede the Capital Delivery department’s ability to effectively track and manage costs for capital projects.Amtrak’s Capital Delivery department is strengthening its ability to track and manage costs. For example, the company is developing a single project management system that it anticipates will replace or integrate at least 12 systems to address the challenge project teams currently have tracking costs across multiple systems. We identified additional challenges, however, with the systems and processes that the department uses for project cost management. Specifically, detailed and standardized cost data are not readily available to project teams, and project cost management guidance is outdated. These challenges hinder project teams and company executives from obtaining consistent, detailed cost data to manage the company’s portfolio of capital work—foundational capabilities that are critical to effectively managing costs on billions of dollars in taxpayer-funded projects.We recommended Amtrak study how it can develop and use more detailed and standardized costs for effective project cost management and then create a plan specifying the people, processes, and systems it needs to do so. While that study is ongoing, we recommended Amtrak develop and implement rules in the short term that define how project teams should categorize costs using existing systems and processes. Finally, we recommended that Amtrak update and implement project cost management procedures to reflect current processes and requirements.