Federal Reports

This report is redacted for privacy reasons.

Program operations staff in the Veterans Benefits Administration (VBA) conduct site visits to regional offices to ensure that veterans service centers follow policies and procedures for disability compensation benefits. The VA Office of Inspector General (OIG) examined whether program operations staff conducted site visits and identified deficiencies at regional offices, and if managers took sufficient follow-up action on frequently identified errors to improve disability claims processing. The OIG found that program operations staff generally identified deficiencies during site visits and communicated results to the relevant offices, which addressed those deficiencies. VBA’s Compensation Service summarized the site visit findings on its internal website, which all regional office managers can review. Staff also conducted trend analyses of deficiencies and shared an informal summary of error trends each year with VBA’s Office of Field Operations, which is responsible for providing direction to regional offices. However, the Office of Field Operations did not fully use the information from site visits to improve claims processing nationwide. The deputy under secretary for field operations expected regional office managers to be aware of issues raised in other regional office site visit reports, but there was no written policy for addressing frequently identified errors. The OIG made three recommendations to VBA for achieving nationwide improvement in the consistency and accuracy of veterans’ claims decisions. These recommendations included a formal annual report from the Compensation Service to the Office of Field Operations on all recurring deficiencies and action items identified by the site visit program during the inspection year, and a recurring action plan to address them. The OIG also recommended that VBA establish a follow-up process to monitor compliance with the new requirement and hold regional office managers accountable for making corrections and addressing action items in a timely manner.

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 Robert J. Dole VA Medical Center and multiple outpatient clinics in Kansas. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The executive leadership team had worked together since 2018. The Director had served in the role since 2016. Employee satisfaction scores revealed opportunities for the Associate Director for Patient Care Services to improve employee attitudes towards senior leaders. Patients appeared satisfied with their care and leaders appeared actively engaged. The OIG identified significant concerns regarding incident review processes and identifying sentinel events and/or institutional disclosures. Leaders were able to speak knowledgeably about performance actions and survey results. Leaders were also generally knowledgeable about Strategic Analytics for Improvement and Learning data. The OIG issued 26 recommendations for improvement in all eight areas: (1) Quality, Safety, and Value • Utilization management data review • Root cause analysis processes • Annual patient safety report (2) Medical Staff Privileging • Professional practice evaluations • Provider exit reviews (3) Environment of Care • Supply storage • Environmental cleanliness • Privacy (4) Medication Management • Behavior risk assessment • Informed consent • Patient follow-up (5) Mental Health • Patient follow-up • Suicide safety plans • Staff training (6) Care Coordination • Multidisciplinary committee (7) Women’s Health • Women Veterans Health Committee membership (8) High-Risk Processes • Annual risk analysis • Airflow and infection control • Endoscope storage

In July 2020, our office issued a report on Amtrak’s management of its police department. Our objective was to evaluate the extent to which Amtrak employed key practices to ensure the efficiency and effectiveness of its police force. When we initiated our assessment, there were no agreed-upon best practices for rail policing in the relevant literature or from discussions with professional organizations and researchers, and there was no commonly accepted list of the top performers. Therefore, we conducted extensive research to develop a list of key practices to assess Amtrak.

To determine these practices, we reviewed and compiled information from a range of public- and private-sector sources. This included information from semi-structured interviews and site visits with 14 of the 16 largest rail organizations in the United States, which cover 90 percent of the nation’s ridership. We also visited national rail police and security departments in Canada, France, Germany, Great Britain, and Italy. We chose these based on expert opinion about high-quality rail police departments and comparable track miles to Amtrak. We then combined the results of our research with commonly accepted management standards.

This guide is intended to share the results of our work by providing the key practices for police management that we identified, which may be applicable to other rail and transit organizations.

See the additional details link below for the full report, report summary, multimedia or any agency follow-up.