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 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.

The objective for this management advisory report was to assess the effectiveness of the company’s management and oversight of the program, including the extent to which it has identified and mitigated schedule and budget risks.We found that the company has taken significant steps to remedy early program management deficiencies on the Moynihan program. This included changes to the program’s leadership and team and significant improvements in cost management, as well as, the development of a reliable schedule. It did not, however, take these actions soon enough to avoid cost increases and ensure that it can complete its entire station relocation by the scheduled opening by the end of 2020. These ongoing cost and schedule risks are the result of ineffective executive oversight coupled with inexperienced program staff during the company’s first two years on the program, and a failure to follow the company’s program management standards. In December 2019, the company changed the program’s leadership and team, assigning trained program and construction managers who significantly improved the program’s structure, management, and oversight. Nevertheless, the new team has not been able to fully recover from these earlier program management deficiencies. Because of this, the company has had to request an additional $72.8 million from the Board of Directors since the program’s start, and parts of the program needed for opening day may be at risk of delays.We did not identify any additional actions that the company could take to better mitigate the risks of delays because of the limited time remaining on the Moynihan program. Continued active program management and ongoing executive oversight will help the company meet its planned schedule for opening the station.

On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). Among its provisions, the CARES Act provided the U.S. Department of the Interior (DOI) with $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas.This report presents the DOI’s progress as of July 31, 2020, in spending CARES Act appropriations. Specifically, the DOI’s expenditures to date total $502,312,984 and its obligations total $599,016,669.We are also monitoring the DOI’s progress on reporting milestones established by the CARES Act and the Office of Management and Budget.We anticipate issuing updated status reports monthly.

The MRC is the Postal Service’s “lost and found” department, serving a vital customer service role by processing undeliverable and lost items. The MRC receives items deemed “undeliverable” from Postal Service facilities throughout the country, including post offices, delivery units, and distribution centers. These items may be designated as undeliverable because of incomplete addresses, damaged mailing labels, etc. The MRC received about 67 million items in fiscal year (FY) 2019. Our objective was to evaluate the effectiveness of U.S. Postal Service Mail Recovery Center (MRC) operations and identify opportunities for improvement.