Federal Reports

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Black Hills Health Care System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 151 employees.Organizational leadership supports patient safety, quality care, and other positive outcomes; however, the facility leaders have opportunities to improve employee satisfaction. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to improve performance of the Quality of Care and Efficiency metrics likely contributing to the current 4-star SAIL rating. OIG noted findings in three of the six areas of clinical operations reviewed and issued six recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are:(1) Coordination of Care: Inter-Facility Transfers• Inter-facility patient transfer data analysis and reporting(2) EOC• EOC rounds attendance• Locked mental health (MH) unit environmental safety• Locked MH unit employee and Interdisciplinary Safety Inspection Team training(3) High-Risk Processes: Moderate Sedation• Assessment of patients’ previous adverse experiences with sedation• Use of checklist for timeout procedure

At the request of former United States Senator Harry Reid, the Office of Inspector General (OIG) reviewed allegations of excessive rent and remodeling costs, lack of radiology services, and inadequate handicap accessibility at the Master Chief Petty Officer Jesse Dean VA Clinic (clinic), which provides primary care to approximately 1,372 veterans in and around Laughlin, Nevada. The OIG found that VA paid excessive lease costs for the clinic when it awarded a 10-year contract at a rate higher than the established fair rental value (FRV). Additionally, VA paid for shell improvement costs for the clinic, which were the lessor’s responsibility. The contract file had no documents to explain or justify the lease’s higher rate, nor was there evidence of any reviews having occurred prior to awarding the lease. As a result, VA may pay as much as 41 percent above FRV over the 10-year lease. The OIG did not substantiate other allegations related to remodeling costs, radiology services, or clinic accessibility. The OIG recommended that VA ensure oversight reviews are conducted and documented prior to the award of leases, contracting officers adhere to acquisition requirements, and awarded lease rates are in the best interest of the government. The OIG also recommended that VA reevaluate the lease to determine the financial advantages and disadvantages of renegotiating the terms of the contract to obtain a FRV commensurate with the Laughlin area.

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA New York Harbor Healthcare System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; Mental Health (MH) Residential Rehabilitation Treatment Program; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 135 employees.The facility has generally stable executive leadership with demonstrated cohesiveness and active engagement with employees and patients. Organizational leaders support patient safety, quality care, and other positive outcomes. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors.OIG noted findings in five of the clinical operations reviewed and issued 14 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are:(1) QSV • Review of ongoing professional practice evaluation data(2) Medication Management: Anticoagulation Therapy• Collection and reporting of quality assurance data• Patient education specific for newly prescribed anticoagulant medications• Employee competency assessments(3) Coordination of Care: Inter-Facility Transfers• Transfer data analyzing and reporting• Documentation of acute patient transfers to other facilities• Communication with accepting facility(4) EOC• EOC rounds attendance• Panic alarm in the locked MH unit• Risk assessment of locked MH unit electric or mechanical beds• MH Interdisciplinary Safety Inspection Team training(5) High-Risk Processes: Moderate Sedation• Reporting and trending of reversal agents and adverse events• Performance of history and physical examinations and pre-sedation assessments• Documentation of informed consent