Federal Reports

Coronavirus disease 2019 (COVID-19) has affected millions of Americans, resulting in more than 600,000 deaths. Medicare beneficiaries have been particularly affected and remain vulnerable to new variants and additional surges of the virus. Clinicians and researchers are still working to fully understand the damage to the body from the disease and what underlying chronic conditions potentially lead to more severe complications or hospitalization.Understanding the types of conditions for which Medicare beneficiaries with COVID-19 are being treated and who was more likely to be hospitalized with COVID-19 can help hospitals and health officials better prepare for and address the wide-ranging and extensive needs of COVID 19 patients, particularly in the event of localized surges of cases. Such knowledge will also assist in the Federal, State, and local response to the pandemic by providing a better picture of the needs of these hospitalized beneficiaries.This report describes the complex care needs of beneficiaries hospitalized with COVID-19. It focuses on surges in COVID-19 hospitalizations in six localities and builds upon prior OIG work that describes the extent to which hospitals have been strained by COVID-19. As we noted in the 2021 report about hospital experiences during the pandemic, hospitals have been operating in "survival mode" for an extended period of time. They have also experienced difficulty balancing the complex and resource-intensive care needed for COVID-19 patients with efforts to resume routine hospital care.

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 Providence VA Medical Center and multiple outpatient clinics in Massachusetts and Rhode Island. 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.The medical center’s executive team had worked together for over seven months at the time of the OIG virtual site visit. The Director was the newest member of the executive team and had served in the role since June 2020. The other team members had been in their positions for more than two years. Employee survey data revealed opportunities for the Chief of Staff and Director to improve feelings of servant leadership and reduce moral distress at work, respectively. Patient experience survey data indicated satisfaction with the care provided.The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were knowledgeable within their scope of responsibilities 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• Systems Redesign and Improvement Program• Surgical work group(2) Care Coordination• Nurse-to-nurse communication

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 VA Salt Lake City Health Care System. 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’s inspection, the Chief of Staff and Director had served in their roles since 2012 and 2017, respectively. However, the remaining three executive leaders had assumed their roles within the past 10 months. Employee survey results demonstrated satisfaction with most executive leaders and maintenance of a work environment where staff felt respected and discrimination was not tolerated. Patient survey results indicated general care satisfaction among male veterans, but opportunities to improve female veterans’ experiences. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders 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 six recommendations for improvement in three areas:(1) Mental Health• Suicide prevention training(2) Care Coordination• Monitoring and evaluation of inter-facility transfers• Transfer form completion• Documentation of active medication lists• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior training