Federal Reports

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 Miami VA Healthcare System. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It 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.The system’s executive leadership team appeared stable, with the exception of the associate director for patient care services position. The position had been vacant since April 2019 and was filled by two different interim staff. Employee satisfaction survey data was generally positive. However, scores for the associate director for patient care services role reflected opportunities to improve staff feelings toward leaders and the workplace. Patient experience survey data indicated overall satisfaction with the care provided, but also revealed concerns with specialty care services. 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 five recommendations for improvement in two areas:(1) Care Coordination• Patient transfer monitoring and evaluation• Transfer documentation• Medication list transmission(2) High-Risk Processes• Staff training

The Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. This report focuses on Southeast district 2 zone 2 and four selected vet centers: Clearwater, Ocala, and Sarasota in Florida; and Ponce in Puerto Rico. The OIG inspection focused on six review areas: leadership and organizational risks; quality reviews; COVID-19 response; suicide prevention; consultation, supervision, and training; and environment of care.Generally, district leaders had a good understanding of quality improvement principles and implemented district-wide quality improvement programs in response to VA All Employee Survey results. District 2 zone 2 Vet Center Service Customer Feedback survey results exceeded national scores. The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policy and procedures. The OIG made four recommendations for clinical and administrative quality reviews and two recommendations for critical incident quality reviews. The COVID-19 response review showed that although initially feeling ill-equipped, district leaders enacted emergency plan procedures and vet centers remained operational. Employees’ response to an OIG questionnaire indicated the pandemic response was well managed by district leaders and vet center directors. The suicide prevention review included a zone-wide evaluation of electronic client records, and a focused review of the four selected vet centers. The OIG issued 10 recommendations—four specific to client records and six for selected vet centers’ suicide prevention and intervention processes. The consultation, supervision, and training review evaluated the four vet centers. The OIG identified concerns with external clinical consultation, supervision, and training, and issued four recommendations. The environment of care review evaluated the four vet centers. The OIG made two recommendations.The OIG issued a total of 22 recommendations for improvement, including three to the Under Secretary for Health and 19 to the District Director.

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. This report focuses on Continental district 4 zone 2 and four selected vet centers: Alexandria in Louisiana and Houston Southwest, Laredo, and Mesquite in Texas. The OIG inspection focused on six review areas: leadership and organizational risks; quality reviews; COVID-19 response; suicide prevention; consultation, supervision, and training; and environment of care.Generally, district leaders were knowledgeable about quality improvement principles and implemented district-wide quality improvement programs in response to VA All Employee Survey results. District 4 zone 2 Vet Center Service Customer Feedback survey results exceeded national scores.The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policy and procedures. The OIG made three recommendations for clinical and administrative quality reviews and two recommendations for critical incident quality reviews.The COVID-19 response review showed district leaders adjusted and figured out what needed to be done to ensure vet centers remained operational. Employees’ response to an OIG questionnaire indicated district leaders and vet center directors were prepared and provided communication to ensure employee and client safety.The suicide prevention review included a zone-wide evaluation of electronic client records, and a focused review of the four selected vet centers. The OIG issued eight recommendations—seven specific to electronic client records and one for selected vet centers’ suicide prevention and intervention processes.The consultation, supervision, and training review evaluated the four selected vet centers, identified concerns with external clinical consultation, supervision, and training, and issued four recommendations.The environment of care review evaluated the four selected vet centers and made three recommendations.The OIG issued a total of 20 recommendations for improvement.

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. This report focuses on Pacific district 5 zone 1 and four selected vet centers—Bellingham and Tacoma in Washington, Central Oregon in Bend, and Wasilla in Alaska. The OIG inspection focused on six review areas: leadership and organizational risks; quality reviews; COVID-19 response; suicide prevention; consultation, supervision, and training; and environment of care.Overall, district leaders had a good understanding about quality improvement principles and implemented district-wide quality improvement programs in response to VA All Employee Survey results. District 5 zone 1 Vet Center Service Customer Feedback survey results were favorable in five of six areas.The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policy and procedures. The OIG made three recommendations for clinical and administrative quality reviews and one recommendation for critical incident quality reviews.The COVID-19 response review showed district leaders were as prepared as possible and able to enact emergency plan procedures to ensure vet centers remained operational. Employees’ response to an OIG questionnaire reflected that communication from district leaders and vet center directors was adequate to ensure the safety of clients and staff.The suicide prevention review included a zone-wide evaluation of electronic client records and a focused review of the four selected vet centers. The OIG issued 11 recommendations addressing eight zone-wide and three selected vet centers’ suicide prevention and intervention processes.The consultation, supervision, and training review evaluated the four selected vet centers, identified concerns with clinical liaison, external clinical consultation, supervision, monthly audits, and training, and issued five recommendations.The environment of care review evaluated the four selected vet centers and made three recommendations.The OIG issued 23 recommendations for improvement.

FY 2021 Report on the FTC’s Top Management and Performance Challenges