Federal Reports

We reviewed Forest Service’s controls over its contract closeout process.

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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 Pittsburgh Healthcare System. 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 Facility leaders, permanently appointed staff who have been working as a team since January 2016, supported patient safety, quality care, and other positive outcomes. However, the presence of organizational risk factors, as evidenced by Patient Safety Indicator data and root cause analyses, may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. The leadership team was knowledgeable about selected SAIL metrics and should continue to take actions to maintain and improve care and performance of selected Quality of Care and Efficiency metrics that are likely contributing to the current “4-Star” rating. The OIG noted findings in two of the eight clinical areas reviewed and issued four recommendations that are attributable to the Deputy Director and Chief of Staff. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (2) Environment of Care • Facility and CBOC environmental cleanliness and maintenance • Inpatient mental health safety

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 Salem 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 OIG noted that Facility leaders appear to be actively engaged with employees and were working to improve inpatient satisfaction scores. Organizational leaders 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). The OIG did not identify any substantial organizational risk factors. The Facility leaders, with the exception of the newly-assigned Acting Associate Director for Patient Care Services, were generally knowledgeable of selected Strategic Analytics for Improvement and Learning metrics and should continue to support care and performance of Quality of Care and Efficiency metrics that contributed to the improvement from the previous “4-Star” to the current “5-Star” rating. The OIG noted a finding in one clinical area reviewed and issued a recommendation that is attributable to the Chief of Staff. The identified area with a deficiency is High-risk Processes: Central Line-associated Bloodstream Infections. A comprehensive Facility policy should be developed and implemented on the use and care of central lines.