Federal Reports

The OIG conducted a review of select aspects of operations and performance at two Veterans Health Administration (VHA) facilities in the same Veterans Integrated Service Network (VISN) that historically ranged from lower performing (Facility A) to higher performing (Facility B).Facilities are usually identified, but the OIG is not disclosing facility names in this report. Given that the focus was on comparing performance characteristics, and not a comprehensive inspection, it was determined not to identify each one.In general, the OIG found that both facilities approached and addressed many patient safety and quality-of-care issues similarly. However, after an in-depth review of data, policies, governance structures, and leadership interviews, the OIG found several factors directly shaped each facility’s ability to accomplish progressively higher performance. The two broad factors were (1) leadership and (2) integration of an effective quality, safety and value (QSV) program and high-reliability organization (HRO) principles. Facility culture and human resource-related considerations affected operations and performance.Most facilities can and should identify, evaluate, and address opportunities to improve patient care and safety within their organizations. VHA facilities that have experienced high leadership turnover and challenges recruiting permanent, high-caliber managers and leaders may benefit from more proactive VISN and VHA support. A careful examination of leadership, strength of the QSV program, and the integration of HRO principles may reveal underlying themes and additional opportunities for improvement.In that this was not a traditional compliance or quality review, the OIG did not make formal recommendations. Rather, the OIG identified opportunities for VISNs to provide meaningful and timely assistance to both struggling and better performing facilities and provided eight suggestions for VISNs to consider. Those suggestions relate to mentors; external evaluation and development teams, leadership assignment, and development and succession planning; quality- and safety-related policy updates; staffing methodology; and meeting minute documentation.

To view our interactive report, click here: https://oig.justice.gov/reports/top-management-and-performance-challeng…

Audit report on the data accuracy of the NLRB's NxGen Case Management System

In keeping with its responsibilities under the Inspector General Act of 1978, as amended, the OIG monitored the audit of TVA's fiscal year 2021 financial statements performed by Ernst and Young LLP (EY) to assure their work complied with Government Auditing Standards. Our review of EY's work disclosed no instance in which the firm did not comply in all material respects with Government Auditing Standards.

The Office of the Inspector General (OIG) performed the procedures, which were requested and agreed to by Tennessee Valley Authority (TVA) management solely to assist management in determining the validity of the Winning Performance/Executive Annual Incentive Plan (WP) Measures for fiscal year (FY) ending September 30, 2021. TVA management is responsible for the WP Measures data provided. In summary, procedures applied by the OIG found: • The FY 2021 WP goals for the Enterprise measures were properly approved. There was one change form that affected one measure.• The FY 2021 goals (target) for the corporate multiplier measures were properly approved. • The actual FY to-date results for the Enterprise measures agreed with the underlying support, without exception.• The actual FY to-date results for the corporate multiplier measures agreed with the underlying support, without exception.• The FY 2021 WP payout percentage provided by the Benchmarking and Enterprise Performance organization on November 5, 2021, was mathematically accurate and agreed with the Office of the Inspector General’s recalculation.

The OIG contracted with the independent certified public accounting firm, Allmond & Company, LLC (Allmond), to audit the Commission’s financial statements and related footnotes. Allmond found the financial statements present fairly, in all material respects, the financial position of the Commission as of September 30, 2021 and 2020, and its net costs, changes in net position, and budgetary resources for the fiscal year then ended in accordance with generally accepted accounting principles. Allmond also found one material weakness and four significant deficiencies in internal control over financial reporting, and one reportable noncompliance with applicable provisions of laws, regulations, and contracts tested. The report offers 23 recommendations to help the Commission improve its controls over financial management operations and reporting.