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 Wm. Jennings Bryan Dorn VA Medical Center and multiple outpatient clinics in South Carolina. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment.The medical center leaders had worked together for nearly two years at the time of the on-site inspection. Survey results indicated that employees were generally satisfied. However, patient survey results indicated multiple opportunities for medical center leaders to improve satisfaction. Review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. Medical center leaders, other than the Chief of Staff, were knowledgeable within their scope of responsibilities about employee and patient satisfaction survey results and Veterans Health Administration data and/or factors contributing to specific poorly-performing Strategic Analytics for Improvement and Learning quality and efficiency measures.The OIG issued 14 recommendations for improvement in six areas:(1) Medical Staff Privileging• Ongoing professional practice evaluations• Provider exit reviews(2) Environment of Care• Infection prevention and medication safety• Environmental cleanliness• Privacy(3) Medication Management• Aberrant behavior risk assessment• Informed consent• Patient follow-up (4) Mental Health• Patient follow-up• Suicide prevention training(5) Women’s Health• Gynecologic care coverage• Women Veterans Health Committee membership and attendance(6) High-Risk Processes• Equipment storage

The Tennessee Valley Authority (TVA) Board of Directors requested we review and assess TVA’s compliance with the requirements of Executive Order 13950, Combating Race and Sex Stereotyping, in the form of a report submitted to the United States Office of Management and Budget. Our review found TVA had complied with those requirements of the Executive Order applicable to TVA.