Federal Reports

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Memphis VA Medical Center (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The OIG also provided crime awareness briefings to 183 employees. The Facility appears to have stable executive leadership that needs to improve patient satisfaction. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results identified recent delivery of poor care and substantial future organizational risks if improvements are not made. The senior leaders should take actions to improve care and performance of SAIL metrics (Quality of Care and Efficiency) likely contributing to the current “1-Star” rating. The OIG noted findings in six areas reviewed and issued 13 recommendations attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value• Documentation of patient safety incidents in WebSPOT database(2) Credentialing and Privileging• Focused and Ongoing Professional Practice Evaluation processes(3) Environment of Care• Attendance of environment of care rounds• Safety and cleanliness of patient care areas• Contamination prevention in equipment storage areas• CBOC medication safety and means of egress• Cleanliness of food service and storage areas(4) Medication Management: Controlled Substances Inspection Program• Completion of annual Controlled Substances Inspector training(5) Long-Term Care: Geriatric Evaluations• Program evaluation and performance improvement(6) High-Risk Processes: Central Line-Associated Bloodstream Infections• Staff training

The Office of Inspector General (OIG) conducted a healthcare inspection at the Colmery-O’Neil VA Medical Center (Facility) in Topeka, Kansas, regarding an anonymous complainant’s allegations that physicians were practicing beyond their clinical privileges and expertise; physicians failed to seek assistance from specialists, thus placing patients at risk; and a nurse practitioner did not have physicians’ help or supervision for the inpatient medical service. The OIG did not substantiate that physicians were practicing beyond their clinical privileges and expertise. However, two providers were granted clinical privileges that exceeded the Facility’s operative and Intensive Care Unit complexity levels. Although the OIG did not substantiate that physicians failed to seek assistance from specialists, specialty care clinics had only one provider to cover each area. The OIG determined that specialty services’ consults were ordered when medically necessary, patient transfers were timely and clinically indicated, and inpatients were transferred if specialists were unavailable. The OIG did not substantiate that a nurse practitioner covered the entire inpatient medical service without help or supervision. Additionally, the OIG determined that the VA Eastern Kansas Health Care System’s bylaws had not been updated to reflect VA’s 2017 amendment to its medical regulations permitting full practice authority for Advanced Practice Registered Nurses. The Facility did not meet Veterans Health Administration surgical complexity requirements for surgeons or anesthesia service. Facility staff could not provide lists of after-hours on-call social workers, mental health staff, specialists, and radiologists. Ultrasound scans were not available during all emergency department hours. The OIG made six recommendations related to providers’ clinical privileges; updating bylaws; requirements for after-hours surgeon staffing, pre-operative risk and anesthesia assessments, and anesthesia service coverage; specialty care consults’ timeliness; on-call specialists’ availability; and timely emergency department specialty resources.

This report responds to a request from the U.S. House Committee on Oversight and Government Reform to review measures the U.S. Postal Service has implemented regarding opioid safety preparedness. Specifically, the congressional inquiry focused on Postal Service procedures, training, and communications related to employee exposure risks to synthetic opioids and opioid overdose medication. Our objective was to assess measures the Postal Service has implemented to prepare its workforce for the risks posed by shipments of synthetic opioids.