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.
| Report Date | Agency Reviewed / Investigated | Report Title | Type | Location | |
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| Department of Veterans Affairs | Comprehensive Healthcare Inspection Summary Report: Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, Fiscal Year 2021 | Review | Agency-Wide | View Report | |
| Government Publishing Office | FY2023 Top Management Challenges | Top Management Challenges | Agency-Wide | View Report | |
| Department of War | Evaluation of DoD Security and Life Support for Afghan Evacuees at Camp Bondsteel | Inspection / Evaluation | Agency-Wide | View Report | |
| Department of the Treasury | FINANCIAL MANAGEMENT: Report on the Bureau of the Fiscal Service’s Description of its Investment and Redemption Shared Services System and the Suitability of the Design and Operating Effectiveness of its Controls for the Period August 1, 2021 to July 31, | Audit | Agency-Wide | View Report | |
| Department of the Treasury | FINANCIAL MANAGEMENT: Report on the Bureau of the Fiscal Service’s Description of its Trust Funds Management Shared Services System and the Suitability of the Design and Operating Effectiveness of its Controls for the Period August 1, 2021 to July 31, 202 | Audit | Agency-Wide | View Report | |
| U.S. Agency for International Development | Financial Audit of the Sustainable Management of Forest Concessions Project, Managed by Green Gold Forestry Per S.A., Cooperative Agreement 72052721CA00004, March 22, 2021, to December 31, 2021 | Other |
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| U.S. Agency for International Development | Financial Audit of Instituto Internacional de Educao do Brasil Under Two Awards in Brazil, for the Year Ended December 31, 2021 | Other |
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View Report | |
| U.S. Agency for International Development | Financial Audit of the Productive Entrepreneurship for Peace Program in Colombia, Managed by Banco De Las Microfinanzas - Bancama S.A. Cooperative Agreement 72051419CA00001, January 1 to December 31, 2021 | Other |
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| U.S. Agency for International Development | Financial Audit of USAID Resources Managed by Mary Joy Ethiopia Development Association Under Agreement 72066320CA00015, January 1 to December 31, 2021 | Other |
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| U.S. Agency for International Development | Financial Audit of USAID Resources Managed by Beza Posterity Development Organization in Ethiopia Under Multiple Awards, January 1 to December 31, 2021 | Other |
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