Federal Reports

What We Looked AtThe Federal Railroad Administration’s (FRA) recent data show that human factors, which include fatigue, remain the leading cause of reportable non-grade crossing train accidents. In particular, the rate of human factor-caused train accidents reached a 14-year high of 1.43 per million train miles in 2022. According to FRA, overseeing railroad fatigue management and compliance with Federal Hours of Service (HOS) requirements is part of the Agency’s ongoing efforts to address the adverse impacts and underlying causes of fatigue in the railroad industry. Given these factors, we assessed FRA’s (1) oversight of HOS compliance, (2) pursuit of civil penalties for HOS violations, and (3) oversight of passenger railroad compliance with fatigue management requirements. What We Found Three FRA staff in two divisions—the HOS subject matter expert (SME) and two fatigue SMEs—oversee HOS compliance and fatigue management for the entire railroad industry. However, the oversight processes and analyses are not fully documented and there is no evidence of risk-based planning. Specifically, there are no detailed procedures documenting how FRA’s staff plan or perform oversight of HOS compliance or required analyses of passenger railroad work schedules and fatigue mitigation plans. FRA also lacks guidance for many HOS violation penalty amounts as well as procedures for producing accurate Annual Enforcement Reports. As a result, FRA does not have the procedures and accurate data necessary to effectively target its limited resources to the highest risk areas or adequately oversee different railroad types. Our Recommendations FRA concurred with all 19 of our recommendations to improve its oversight of HOS and fatigue management and provided appropriate actions and completion dates. We consider these recommendations resolved but open, pending completion of planned actions.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Black Hills Health Care System, which includes the Fort Meade and Hot Springs VA Medical Centers and multiple outpatient clinics in Nebraska, North Dakota, South Dakota, and Wyoming. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued four recommendations for improvement in three areas:1. Medical staff privileging• Completion of Ongoing Professional Practice Evaluations• Review of Ongoing Professional Practice Evaluation data and documents2. Environment of care• Completion of environment of care inspections3. Mental health• Completion of Comprehensive Suicide Risk Evaluations

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the VA Ann Arbor Healthcare System, which includes the Lieutenant Colonel Charles S. Kettles VA Medical Center and multiple outpatient clinics in Michigan and Ohio. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (focusing on suicide prevention initiatives)The OIG issued one recommendation for improvement in the Mental Health area of review regarding ensuring providers complete the Comprehensive Suicide Risk Evaluation on the same calendar day as a patient’s positive suicide risk screen in all ambulatory care settings.