Federal Reports

For our final report on our audit of the United States Patent and Trademark Office’s (USPTO’s) management of trademark pendency, our objective was to determine whether USPTO exercised effective oversight and management of trademark pendency. Specifically, we assessed USPTO’s development, monitoring, and reporting of trademark pendency measures, as well as the effectiveness of selected pendency reduction efforts. We found that despite some progress in reducing pendency from its highest levels, USPTO still needs to improve oversight of trademark application pendency. Specifically, we found that I. USPTO missed its pendency targets for multiple years and provided insufficient information in its reporting of pendency goals and results and II. USPTO’s projections of future pendency reduction may not be achievable.

The Reports Consolidation Act of 2000 (Public Law 106-531) requires the OIG to annually summarize what it considers to be the most serious management and performance challenges facing the U.S. Nuclear Regulatory Commission. The Act also requires the OIG to briefly assess the agency’s progress in addressing those challenges.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review allegations regarding the heart transplant program and the performance and behavior of the cardiothoracic section chief (section chief). The OIG also reviewed the temporary inactivation of the heart transplant program and factors associated with reactivation, and Veterans Integrated Service Network (VISN) and facility leaders’ responses to staff concerns about the heart transplant program.

The OIG did not substantiate that the section chief’s surgical patient outcomes, including morbidity and mortality rates, and the facility’s readmission rates statistically varied from national averages to warrant further assessment by the National Surgery Office.

The OIG was unable to determine whether the section chief had “incredibly long” cardiopulmonary bypass times and was not able to draw a conclusion regarding current versus historical cardiopulmonary bypass times for the section chief. The OIG noted facility staff performed a low volume of transplants, which may contribute to variations in outcomes.

The OIG substantiated the section chief repeatedly exhibited unprofessional conduct toward staff, and determined facility and surgical leaders failed to create a culture of safety to ensure staff felt comfortable reporting concerns.

The OIG found VISN leaders failed to ensure a timely quality of care review of cardiothoracic cases; however, the VISN Chief Medical Officer identified further concerns in the heart transplant program that were addressed promptly.

The OIG made two recommendations to the Under Secretary for Health related to a comprehensive review of the transplant program and oversight of quality measures; one recommendation to the VISN Director regarding completion of facility leaders’ requests for clinical care reviews; and three recommendations to the Facility Director including a clinical care review, a review of the section chief’s conduct, and a review of staff’s concerns and development of a culture of safety.