Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review surgical service and quality management concerns at the Hampton VA Medical Center (facility) in Virginia.The OIG found facility leaders conducted three focused clinical care reviews (FCCRs) in response to concerns about the assistant chief of surgery’s surgical care. However, facility leaders failed to report the results of two FCCRs and delayed reporting the results of one FCCR to the Medical Executive Committee, and did not use multiple reviewers for interrater reliability in any of the FCCRs to ensure the reviews were “fair and objective.” Facility leaders took several privileging actions against the assistant chief of surgery. However, the OIG found multiple deficiencies with notification letters and processes, including failure to adhere to VHA policy, send extension letters, include required language within the letters, and use clear terminology. Leaders also failed to report the assistant chief of surgery to the state licensing board after identifying six cases of substandard care.Surgical staff did not complete required patient safety reports. Morbidity and mortality conferences were held in a manner that compromised the formal peer review process and resulted in negative staff experiences. The chief of surgery did not recognize the need for three substandard cases to be considered for peer review. The VISN Chief Medical Officer and the facility chief of quality, safety, and value failed to prevent a management review from including two cases that were being peer reviewed concurrently. The OIG determined that facility leaders generally did not communicate and document required institutional disclosure elements.Eleven recommendations were made to the facility director regarding FCCRs, privileging actions, state licensing board reporting, professional practice evaluations, patient safety reporting, morbidity and mortality conferences, peer review, and institutional disclosures. One recommendation was made to the VISN Director.

On December 19, 2023, the Office of Special Counsel referred a whistleblower disclosure in which a Social Security Administration (SSA) employee alleged that, “SSA Claims Examiners are not informing claimants about the potential detriment of electing to apply for spousal benefits prior to full retirement age.” The Agency referred that allegation to the Office of the Inspector General for review.

What We Looked At The Office of Inspector General (OIG) maintains a hotline for receiving allegations of fraud, waste, abuse, or mismanagement affecting U.S. Department of Transportation (DOT) programs or operations. OIG received a hotline complaint alleging a hostile work environment in the Federal Aviation Administration’s (FAA) Acquisition and Fiscal Law Division (AGC-500). The Division provides legal support to FAA regarding Government contract and acquisition, fiscal, and real property laws. We initiated an audit after reviewing the hotline complaint because its concerns extended beyond a matter for human resources to having potential programmatic effects that could impact the Division’s ability to conduct its mission. Accordingly, our audit objective was to determine if the work environment impacts AGC-500’s ability to fulfill its mission to provide legal support for the NAS.What We Found AGC-500’s work environment impacts its ability to meet its mission and provide legal support to FAA as the Division is experiencing high attorney turnover, employee dissatisfaction, and inefficient decision making. These issues are partly because of attorney dissatisfaction with AGC senior leadership. As a result, FAA faces unanticipated costs, potential safety burdens, and potential challenges meeting its mission. Furthermore, AGC-500 cases are not formally tracked and lack transparency. While FAA has made improvements to address issues with its documentation system, the tool will not be effective until all AGC-500 attorneys are trained on and use the system to share program information and formally document their work. In addition, AGC-500 adopted guidelines in 2022 that could conflict with employees’ whistleblowing rights and could interfere with OIG’s investigations. In November 2023, after discussion with OIG’s legal counsel, AGC-500 drafted an improved business rules document. However, until the Division officially updates its business rules, employees’ ability to fulfill their mission with the protections afforded to all Federal workers will remain at risk.Our Recommendations We made six recommendations to enhance the AGC-500’s operating environment and ability to complete its mission efficiently. The Agency concurred with all six recommendations, which we consider resolved but open pending completion of planned actions.