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 Samuel S. Stratton VA Medical Center. The inspection covered key clinical and administrative processes 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; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the inspection, the executive team had worked together in a permanent capacity for approximately six months; however, multiple leaders had served in their positions for more than two years. Employee survey data revealed that staff were satisfied with leadership and felt respected, and discrimination was not tolerated. Overall, outpatient satisfaction survey results were generally higher than VHA averages, but highlighted opportunities to improve access to specialty care appointments. Inpatient survey scores were generally lower than the VHA averages and indicated opportunities to improve experiences for both genders.The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures of adverse patient events did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue taking actions to sustain and improve performance.The OIG issued 10 recommendations for improvement in three areas:(1) Quality, Safety, and Value• Surgical work group attendance• National Surgery Office quality report review(2) Care Coordination• Inter-facility transfer policy• Transfer monitoring, evaluation, and form completion• Medication list transmission• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior committee attendance• Risk assessment participation• Staff training

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The Semiannual Report to Congress summarizes the results of VA OIG oversight, provides statistical information, and lists all reports issued from October 1, 2021, to March 31, 2022. During this reporting period, VA OIG audits, evaluations, investigations, inspections, and other reviews identified nearly $4.1 billion in monetary impact for a return on investment of $41 for every dollar spent on oversight. During this reporting period, the VA OIG issued 143 reports and publications on VA programs and operations, made 397 recommendations, and conducted investigations that led to 104 arrests.

The Office of the Inspector General conducted a review of the Browns Ferry Nuclear Plant Radiation Protection (BFN RP) organization to identify factors that could impact BFN RP’s organizational effectiveness. During the course of our evaluation, we identified behavioral and operational factors that are negatively impacting BFN RP’s effectiveness and its ability to meet its responsibilities and support Nuclear’s vision and core principles. Most employees expressed having positive relationships with individuals in their own groups, and many indicated they trusted their coworkers to perform their jobs well. However, multiple negative behavioral factors were also expressed, including:• Concerns regarding interactions between BFN RP groups.• Concerns regarding management interactions.• Perceptions of (1) unethical and (2) noninclusive behaviors by certain managers.• Perceptions that BFN RP personnel cannot stop work and plant operations are placed before radiation safety.In addition, we were informed about concerns related to outdated instrumentation and equipment, inadequate supplies, the briefing room environment, and budget and staffing constraints. We also identified a risk related to the oversight and monitoring of the nuclear safety culture within BFN RP that could impact BFN as a whole.