Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Iowa City VA Health Care System, which includes the Iowa City VA Medical Center and multiple outpatient clinics in Illinois and Iowa.This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (emergency department and urgent care center suicide prevention initiatives)The OIG issued six recommendations for improvement in four areas:1. Leadership and Organizational Risks• Institutional disclosures for sentinel events2. Quality, Safety, and Value• Adverse event investigations3. Medical Staff Privileging• Service-specific criteria in Ongoing Professional Practice Evaluations• Practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations4. Environment of Care• Patient areas are clean, safe, and suitable• Panic alarm testing

The U.S. Department of Agriculture Office of Inspector General’s Annual Plan for Fiscal Year 2024 describes how OIG plans to accomplish its mission of promoting economy, efficiency, effectiveness, and integrity in the delivery of USDA programs during the fiscal year.

What We Looked At
As required by law, we report annually on the Department of Transportation’s (DOT) most significant challenges to meeting its mission. We considered several criteria to identify DOT’s top management challenges for fiscal year 2024, including impact on safety, documented vulnerabilities, large dollar implications, and the Department’s ability to effect change. Furthermore, in light of the nearly $660 billion in funding authorized by the Infrastructure Investment and Jobs Act (IIJA) to bolster the Nation’s transportation infrastructure, our report also discusses IIJA’s impact on each of the 10 management challenge areas we identified.

What We Found
We identified the following top management challenge areas for fiscal year 2024:

Aviation safety. Key challenges: enhance FAA’s oversight of aircraft certification and production, and diagnose root causes to prevent and mitigate runway incursions.

Surface transportation safety. Key challenges: identify root causes and implement safety programs to reduce fatalities and verify and enforce railroad, transit, pipeline, and hazardous materials safety compliance.

Air traffic control and airspace modernization. Key challenges: understand and address the causes of flight delays and cancellations and recover from and assess the impact of delayed and diminished NextGen programs on Agency costs and benefits for airspace users.

Surface transportation infrastructure. Key challenges: steward surface transportation investments in a changing environment, support effective funding oversight as IIJA progresses, and advance a range of surface transportation priorities and goals.

Contract and grant fund stewardship. Key challenges: award contract and grant funds to achieve the best outcomes and verify efficient and appropriate use of contract and grant funds.

Financial management. Key challenges: reduce the occurrence of improper payments, improve compliance with Federal requirements for monitoring and reporting on grantee spending, and improve the quality of financial data.

Information security. Key challenges: overcome obstacles to mitigate longstanding weaknesses in DOT’s cybersecurity program, and execute Federal priorities to move towards a Zero Trust Architecture.

Fraud prevention and detection. Key challenges: identify and assess fraud risks, and manage fraud risks through oversight, outreach, and data analysis.

Transportation transformation. Key challenges: advance safety and other DOT missions through the innovation principles, safely advance emerging and innovative vehicle technologies, and integrate new technologies into the NAS.

Organizational excellence. Key challenges: establish the workforce capabilities needed to meet the Department’s mission, manage an evolving workplace environment, and cultivate data-driven approaches to support policymakers and manage the mission.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Mann-Grandstaff VA Medical Center in Spokane, Washington. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (focusing on suicide prevention initiatives)The OIG issued six recommendations for improvement in three areas:1. Quality, safety, and value• Peer Review Committee summary analysis data• Executive-level medical committee review2. Environment of care• Safe work practices• Clean and sterile storeroom access3. Mental health• Suicide-related event reporting• Completion of Comprehensive Suicide Risk Evaluations

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network 21: VA Sierra Pacific Network in Pleasant Hill, California. This evaluation focused on five key areas of clinical and administrative operations:• Leadership and organizational risks• Quality, safety, and value• Medical staff credentialing and privileging• Environment of care• Mental health (focusing on suicide prevention)The OIG did not issue recommendations for improvement related to the areas reviewed for this report.