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 VA Central Western Massachusetts Healthcare System in Leeds, which includes multiple outpatient clinics in Massachusetts. 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; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.The executive leadership team had worked together for seven months at the time of the OIG virtual review. Survey data revealed opportunities for the Director to reduce employee feelings of moral distress and improve workgroup respect and sharing of concerns. The healthcare system’s patient experience scores were generally higher than VHA averages, except for female patients’ access to timely outpatient appointments. The OIG’s review of the hospital’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were 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 five recommendations for improvement in two areas:(1) Care Coordination• Patient transfer monitoring and evaluation(2) High-Risk Processes• Disruptive behavior committee meeting attendance• Order of Behavioral Restriction and patient notification documentation• Completion of training

The VA Office of Inspector General (OIG) evaluated an August 2019 hotline complaint alleging mismanagement of supplies, equipment, and operating rooms while activating the New Orleans VA Medical Center in Louisiana.The OIG substantiated that the medical center purchased about $1.85 million in excess surgical supplies. Employees also violated VA supply chain management policies by not properly accounting for nor advertising the excess supplies to other facilities. Employees violated Federal Acquisition Regulations and VA financial policy when they used purchase cards instead of contracts to obtain supplies.The OIG did not substantiate that the facility purchased unnecessary equipment, nor that funds were wasted on purchasing surgical equipment and related service contracts. The OIG was unable to determine if operating rooms were underused because sufficient data on percentage of surgeries being outsourced were not available. However, the OIG substantiated that two operating rooms were not being used two years after the surgical department opened and the department’s activation was delayed. Employees provided evidence supporting the decisions to not yet open all the operating rooms. COVID-19 also affected delays in surgical department activation.The OIG recommended the Southeast Louisiana Veterans Health Care System director account for undocumented excess supplies and determine if any administrative action should be taken on some $675,000 in missing supplies listed in a report of survey. The director should also ensure identified FAR violations are reported to the Financial Services Center, appropriate remedies or penalties are imposed, and all unauthorized commitments are ratified per policy. The director should ensure employees coordinate with and obtain guidance from National Purchase Card Program staff when they are uncertain about proper use of government purchase cards. Leased equipment should be returned to the contractor for any operating rooms that will not be used for at least one year.