Federal Reports

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 James A. Haley Veterans’ Hospital. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the OIG virtual review, the executive team had worked together for approximately six months. The Associate Director for Patient Care Services, assigned in April 2010, was the most tenured leader. In June 2020, the Director was detailed to the Veterans Integrated Service Network and the Deputy Director and Associate Director were promoted to acting roles as the Director and Deputy Director, respectively.Employee satisfaction survey responses were generally positive. However, the responses highlighted opportunities for the Associate Director for Patient Care Services and Associate Director to adopt servant leadership traits. Patient experience survey scores were generally similar to or more favorable than the corresponding VHA averages, but leaders could improve access to urgently needed outpatient appointments. The Director, Chief of Staff, and Associate Director for Patient Care Services were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.The OIG issued three recommendations for improvement in two areas:(1) Quality, Safety, and Value• Surgical work group review process(2) High-Risk Processes• Disruptive behavior committee review process• Staff training

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 Bay Pines Healthcare System and eight outpatient clinics in Florida. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; High-Risk Processes: Management of Disruptive and Violent Behavior.When the team conducted this inspection, the executive team had worked together for nine months. All staff were permanently assigned. Employee survey responses demonstrated satisfaction with leadership and maintenance of an environment where staff felt respected and discrimination was not tolerated. However, responses also highlighted opportunities to reduce staff feelings of moral distress at work. Patient experience survey data implied satisfaction with the care provided. Further, the OIG found that selected survey results for female respondents were generally more favorable than those for female VHA patients nationally. The OIG identified an opportunity to strengthen the tracking of sentinel events that warrant institutional disclosure. Executive leaders were knowledgeable within their scope of responsibilities about selected VHA data used by the Strategic Analytics for Improvement and Learning models.The OIG issued five recommendations for improvement in four areas:(1) Leadership and Organizational Risks• Disclosure of adverse events(2) Quality, Safety, and Value• Surgical work group processes(3) Mental Health• Suicide prevention training(4) High-Risk Processes• Disruptive behavior committee attendance• Patient notification

We determined that ICE did not always comply with segregation reporting requirements and did not ensure detention facilities complied with records retention requirements.

Inspector General’s Assessment of the Most Serious Management and Performance Challenges Facing the Commodity Futures Trading Commission FY2021