Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a descriptive evaluation of VHA facilities’ leadership and organizational risks. The report focuses on executive leadership position stability and engagement, budget and operations, staffing, employee satisfaction, patient experience, accreditation surveys and oversight inspections, factors related to possible lapses in care, and VHA performance data.This report describes observations from healthcare inspections performed at 45 VHA medical facilities from November 30, 2020, through August 23, 2021. Each inspection involved interviews with key staff and reviews of clinical and administrative processes. The results in this report are a snapshot of VHA performance at the time of the fiscal year 2021 OIG reviews.The OIG did not issue recommendations but developed this summary report for the Under Secretary for Health, Veterans Integrated Service Network directors, and facility senior leaders to consider when improving operations and clinical care at VHA facilities.

We audited costs claimed and grant compliance by the Mississippi Department of Marine Resources under grants awarded by the FWS.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of Veterans Health Administration (VHA) facilities’ quality, safety, and value (QSV) programs. This report describes findings from healthcare inspections performed at 45 medical facilities during fiscal year 2021 that focused on facility committees responsible for QSV oversight functions, systems redesign and improvement programs, protected peer reviews of clinical care, and medical center surgical programs.Each inspection involved interviews with key staff and reviews of clinical and administrative processes. The OIG found general compliance with many of the selected requirements. However, the OIG identified weaknesses with protected peer review and facility surgical work groups and issued three recommendations for• peer review committee documentation of individual improvement actions for Level 3 peer reviews,• surgical work groups that meet at least monthly with consistent attendance by required members, and• surgical work groups’ monthly review of surgical deaths.

The Reports Consolidation Act of 2000 requires the Executive Branch Inspectors General to identify and report annually on the top management challenges facing their agencies.