Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a descriptive evaluation of Veterans Health Administration facilities’ leadership and organizational risks. The report focuses on executive leadership position stability and engagement, accreditation surveys and oversight inspections, factors related to possible lapses in care, and Veterans Health Administration performance data.This report describes observations from healthcare inspections performed at 36 VHA medical facilities from November 4, 2019, through September 21, 2020. Each inspection involved interviews with facility leaders and staff and reviews of administrative processes. The OIG reviewers evaluated meeting minutes and other relevant documents. The results in this report are a snapshot of VHA performance at the time of the fiscal year 2020 OIG reviews.The OIG found that leaders were generally knowledgeable about their facilities and various performance metrics and could speak to actions taken to improve their respective facility’s performance. The OIG observed that lower complexity facilities had fewer reported sentinel events than higher complexity facilities.

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 of Hampton VA Medical Center. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; 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.Medical center leaders had worked together for about four months at the time of the OIG virtual review. Employee survey data revealed opportunities for the Associate Director for Patient Care Services to improve servant leadership and the Chief of Staff to reduce employee feelings of moral distress at work. Patient survey respondents expressed less satisfaction with their inpatient and outpatient care experiences than VHA patients nationally. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.The OIG issued six recommendations for improvement in five areas:(1) Quality, Safety, and Value• Surgical work group attendance(2) Registered Nurse Credentialing• Primary source verification of licenses(3) Mental Health• Suicide prevention training(4) Care Coordination• Transfer form completion(5) High-Risk Processes• Disruptive behavior committee attendance• Staff training

The U.S. Environmental Protection Agency's Office of Inspector General has identified a critical vulnerability concerning software installations on EPA-furnished computers. While information security oversight is the responsibility of the EPA Office of Mission Support, the OIG has identified several instances of unknown third-party threat actors accessing EPA-furnished computers.