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
| Report Date | Agency Reviewed / Investigated | Report Title | Type | Location | |
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| Department of Veterans Affairs | Comprehensive Healthcare Inspection of the VA Central Western Massachusetts Healthcare System in Leeds | Review |
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| Department of Veterans Affairs | Excess Purchase of Surgical Supplies and Improper Purchase Card Transactions at the New Orleans VA Medical Center in Louisiana | Review |
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| Department of Justice | Audit of the United States Marshals Service's Awarding and Administration of Sole-Source Contracts | Audit | Agency-Wide | View Report | |
| Department of Justice | Audit of the Money Laundering and Asset Recovery Section’s Administration of the Equitable Sharing Program | Audit | Agency-Wide | View Report | |
| Office of Personnel Management | Audit of the Information Technology Security Controls of the U.S. Office of Personnel Management’s Benefits Financial Management System | Audit | Agency-Wide | View Report | |
| U.S. Agency for International Development | Closeout Audit of the Innovations and Multi-Sectoral Partnerships to Achieve Control of Tuberculosis Project Managed by the Philippine Business for Social Progress, Inc., Cooperative Agreement AID-492-A-12-00014, October 1, 2017, to July 31, 2018 | Other |
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| U.S. Agency for International Development | Financial Audit of the MENTOR Initiative Under Multiple USAID Agreements for the Fiscal Year Ended September 30, 2017 | Other |
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| U.S. Agency for International Development | Financial Audit of USAID Resources Managed by Amref Health Africa in Multiple Countries Under Multiple Awards, January 1 to December 31, 2020 | Other |
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| U.S. Agency for International Development | Financial Closeout Audit of USAID Resources Managed by Council for Scientific and Industrial Research - Savanna Agricultural Research Institute in Ghana Under Agreement 641-A18-FY14-IL#03, January 1, 2019, to March 31, 2020 | Other |
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| U.S. Agency for International Development | Financial Audit of USAID Resources Managed by Northern Rangelands Trust in Kenya Under Multiple Awards, January 1 to December 31, 2020 | Other |
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