Federal Reports

Management Advisory Memorandum Regarding Interagency Agreements and Whistleblowing Rights

An Amtrak foreman based in Chicago, Illinois, was terminated from employment on June 25, 2024, following an administrative hearing. Our investigation found that the employee violated company policies by falsely reporting in the company’s Work Management System that required safety inspections had been completed for the stairs on three Venture Cars in Chicago. As a result, these cars, which should have been taken out of service, were put into service the following morning. Once we determined the required safety inspections were not completed, we notified management, and the inspections of the cars were completed.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review how facility leaders’ actions may have impacted intensive care unit (ICU) coverage, patient care, and resident education at the VA Eastern Colorado Health Care System in Aurora (facility).The OIG was unable to determine whether facility leaders implemented surgical ICU changes without adequate planning in April 2022. However, the OIG found that the subsequent lack of ICU provider coverage for surgical patients adversely affected the provision of cardiothoracic (CT) surgical services. CT surgeries were paused from September 2022 through August 2023 and the newly appointed Chief of Staff failed to notify VA Central Office through the Veterans Integrated Service Network (VISN) of the pause. The OIG substantiated that leaders’ actions to change the medical ICU from an open to a closed model were made without adequate planning and input from service and section leaders and staff. The OIG substantiated that the sudden implementation of a closed ICU model resulted in a lack of ICU resident supervision and an ineffective teaching environment for residents. The OIG did not substantiate that the medical ICU model change resulted in patient harm; however, the OIG identified a deficiency in the facility’s completion of a root cause analysis.The OIG made one recommendation to the Under Secretary for Health to evaluate the VISN leaders lack of awareness of the CT surgical pause; three recommendations to the VISN Director related to CT surgeries, facility high reliability organization implementation, and residents’ education needs; and two recommendations to the Facility Director related to call escalation and root cause analysis training.