Federal Reports

In follow-up to the VA Office of Inspector General (OIG) report, Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas, the OIG conducted a healthcare inspection to evaluate progress in responding to pathology reading errors identified during a look-back review of cases interpreted by Dr. Robert Levy between September 2005 and October 2017. The OIG determined facility processes related to disclosure of the pathology errors and amending patients electronic health records generally met Veterans Health Administration policy requirements, but opportunities for improvement existed.Look-back reviewers categorized cases according to their disagreement with the original diagnosis and potential harm to the patient (level 0–3). Cases categorized as level 2 or level 3 diagnostic errors were referred to a Clinical Review Team to determine the impact on patient care and need for clinical and institutional disclosure. The OIG determined the facility made reasonable efforts to conduct disclosures, completing all but six of the institutional disclosures and 76.5 percent of the clinical disclosures recommended by the Clinical Review Team. The OIG noted an absence of a clearly defined process for clinical providers to alert the Clinical Review Team if later changes in a patient’s health required reconsideration of institutional disclosure.The look-back review coordinator entered amended pathology reports into the electronic health record for patients identified with level 3 diagnostic errors. However, the facility struggled with completing amended reports for patients with level 2 diagnostic errors—fewer than 5 percent of the level 2 amended reports were completed as of March 2021.The OIG made two recommendations to the Under Secretary for Health related to documentation of clinical disclosures and provider communication to the Clinical Review Team. One recommendation was made to the Facility Director related to amendment of the remaining pathology reports.

The Postal Service’s customer care phone number, 1-800-ASK-USPS, is one of the primary channels for customers to connect with the Postal Service. When customers call 1-800-ASK-USPS, their call is initially handled by an Interactive Voice Response (IVR) system. Using voice commands or keypad inputs, customers can navigate the IVR system to get information or complete tasks, such as finding the location and hours of post offices or tracking a package. Survey results suggest that customer experiences with the Postal Service’s IVR system are improving. Between FY 2019 and FY 2020, customers reported improved satisfaction with the IVR experience and more customers reported their inquiry was resolved. However, opportunities exist for continued improvement. In FY 2020, roughly one-quarter of IVR survey respondents were very dissatisfied with their IVR experience.

Mail is processed manually when its dimensions or address quality prevent it from being processed on mail processing equipment or to meet service standards when machines are at capacity.Processing mail manually is less productive (which is calculated by dividing mailpieces processed by workhours charged) and more costly than processing mail on machines, impacting overall efficiency. Specifically, the Postal Service’s automated processing is six times more productive for letters and flats and nearly four times more productive for packages than processing manually. Our objective was to assess the efficiency of the Postal Service’s manual mail processing operations.

The Office of the Inspector General conducted a review of the Transmission Field Operations, North Maintenance organization to identify factors that could impact its organizational effectiveness. During the course of our evaluation, we identified behaviors that had a positive impact on Transmission Field Operations – North Maintenance; however, we also identified needed improvements related to coworker interactions with a few employees. We also identified minimal risks to operations related to resource concerns, including inadequate staffing and equipment and/or tool needs.

We found issues in the FWS’ contract evaluation and award process and documentation related to certified cost or pricing data requirements.

We present the status of ONHIR’s grazing responsibilities and activities on Navajo Nation land in Arizona known as the New Lands.

We present the status of ONHIR’s operation of the Padres Mesa Demonstration Ranch on Navajo Nation land in Arizona known as the New Lands.

We present the status of ONHIR’s range maintenance responsibilities and activities on Navajo Nation land in Arizona known as the New Lands.