Federal Reports

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Robley Rex VA Medical Center. 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: Posttraumatic 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 Director and Associate Director positions were covered with interim appointees until the positions were permanently filled in August 2018 and January 2018, respectively. The leaders were generally engaged with employees and patients as evidenced by high satisfaction scores. Organizational leadership supported patient safety and quality care. The 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; however, opportunity exists to improve care and positively affect Quality of Care and Efficiency metrics likely contributing to the Facility’s “3-Star” rating. The OIG noted findings in five of the eight clinical areas reviewed and issued nine recommendations attributable to the Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data • Root cause analysis action feedback to reporting employees or departments (2) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (3) Environment of Care • Facility and CBOC cleanliness and maintenance • Inpatient mental health safety • Emergency Operations Plan and annual review of inventory and assets (4) Medication Management: Controlled Substances Inspection Program • Controlled Substances Coordinator’s monthly summary of findings • Annual physical security survey (5) Women’s Health: Mammography Results and Follow-up • Mammogram results electronically linked to radiology order

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 Durham VA Medical Center. 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: Posttraumatic 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. Facility leaders were actively engaged with employees and patients and were working to improve employee satisfaction scores by utilizing additional patient survey data and Town Hall meetings. Organizational leaders appeared to support efforts related to patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the Facility through active stakeholder engagement). However, the presence of organizational risk factors, as evidenced by a lack of identification and reporting of sentinel events and institutional disclosures, may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. Although the leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning metrics, the leaders should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics that are likely contributing to the “3-Star” rating. The OIG noted findings in two of the eight clinical operations reviewed and issued two recommendations that are attributable to the Director and Chief of Staff. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused Professional Practice Evaluation process (2) Medication Management: Controlled Substances Inspection Program • Pharmacy prescription pad accountability

This report presents the results of our audit of the Small Business Administration’s (SBA’s) district offices’ customer service. We initiated the audit in response to a congressional request about the perceived disparity in the effectiveness of SBA district offices. SBA’s district offices promote economic development, growth, and competitiveness within their geographic areas. District offices offer a variety of services to small businesses such as consulting, capital, and counseling programs that help customers start and grow their businesses. SBA has 68 district offices located throughout the United States and its territories. The Office of Field Operations (OFO) oversees district offices to ensure accountability and responsible stewardship of taxpayer dollars. OFO is responsible for the agencywide delivery of SBA’s products and services, which include training, technical assistance, and outreach. The audit objective was to determine whether OFO has a process in place to assess customer service effectiveness at district offices.We determined SBA did not have an effective process in place to assess customer service. Specifically, SBA had not assessed customer feedback to evaluate the quality of customer service provided by district offices. Quality customer service is essential to SBA’s mission to deliver services that aid and protect the interest of small businesses. SBA cannot identify early opportunities to improve customer service or determine whether there are disparities in the Agency’s delivery of service if it does not implement a customer feedback process. Since SBA did not evaluate customer feedback, we conducted a survey of 217 SBA customers. The majority of customers provided positive feedback; however, 32 customers commented that district employees did not always understand their needs and provide them with guidance and support.In addition, the ACR system, which tracks employees’ customer service activities, did not have sufficient controls to preserve the integrity of the district offices’ performance data. As a result, SBA cannot rely on the ACR data to measure progress toward meeting its strategic goals, or the effectiveness of its customer service efforts. Also, district directors did not effectively use ACR data to plan and strategize where to focus employees’ outreach activities. Consequently, employees may not be focusing their efforts in areas most in need of SBA resources, such as access to lenders and capital.OIG made four recommendations to enhance the overall management of District Offices’ Customer Service. SBA’s planned actions should resolve the four recommendations.

The VA Office of Inspector General (OIG) conducted a healthcare inspection addressing confidential allegations of a patient’s delays in renal cancer care and lack of care coordination at the Cheyenne VA Medical Center (Cheyenne), Wyoming, and the Iowa City VA Health Care System (Iowa City), Iowa. The OIG substantiated that Cheyenne clinicians failed to provide timely and proper surveillance (follow-up) for the patient’s renal cell carcinoma and left nephrectomy (kidney) surgery. Contributing factors included a lack of clear communication among providers through electronic health record documentation, inaccurate diagnostic coding on the patient’s problem list, and limited patient evaluations. Additionally, an institutional disclosure and peer reviews were not initiated. The OIG did not substantiate that Iowa City providers failed to provide care and were unaware of the patient’s cancer history. Although Iowa City providers documented the patient’s history of a left nephrectomy, an e-consult to Urology Service for further evaluation was not addressed timely and resulted in a delay in care. Additionally, the OIG found issues with the providers’ problem list documentation and peer reviews were not initiated for the patient’s care. The OIG reviewed additional Iowa City patients’ electronic health records to determine if those urology consults were timely and found that clinical care was provided and patients were not negatively impacted. However, Urology Clinic providers did not always complete e-consult documentation as required by Veterans Health Administration policy. The OIG made five recommendations to the Cheyenne Director related to timely surveillance for cancer patients, care coordination and communication between Cheyenne providers and non-VA providers for cancer patients, problem lists documentation, and initiation of institutional disclosure and peer reviews for the patient’s care. The OIG made two recommendations to the Iowa City Director related to documentation of patients’ problem lists and initiation of peer reviews for the patient’s care.

The overall assessment of the Commission’s information security program was deemed effective because of the ratings throughout the IG Federal Information Security Modernization Act of 2014 (FISMA) Reporting Metrics domain. Due to the success demonstrated by the Commission’s compliance with FISMA, there are no new recommendations in this report. We found the Commission made significant progress to develop, document, and implement agency-wide information security measures that support its operations. The Commission improved ITsecurity and completed most actions needed from prior year recommendations.

Performance Audit of RRB's Compliance with the Federal Information Security Modernization Act of 2014 Fiscal Year 2018

Management Information Report: Limited Oversight of the National Railroad Retirement Investment Trust Puts Railroad Retirement Assets at Risk