Federal Reports

Our objective was to evaluate the throughput and productivity performance of the U.S. Postal Service’s 33 deployed Small Package Sorting System (SPSS) machines. We found that on average nationally, the SPSS machine throughput performance goal was exceeded by about five percent from January 1, 2016, through July 31, 2017. We also found that on average nationally, the Postal Service was not meeting its SPSS productivity goal by about 17 percent from January 1, 2016, through July 31, 2017.

Results of the audit of the Commission’s financial statements for the fiscal year ended September 30, 2017

Report Summary: 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 Long Beach Healthcare System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. OIG also provided crime awareness briefings to 151 employees.The facility has generally stable executive leadership to support patient safety and quality care. However, the presence of multiple organizational risk factors, such as adverse event disclosures, reported in-hospital complications, and adverse events following surgeries and procedures, may contribute to future issues of lapses in patient safety unless corrective processes are implemented and continuously monitored. Facility leaders should continue to take actions to improve performance of selected Strategic Analytics for Improvement and Learning metrics, particularly Quality of Care metrics.OIG noted findings in five areas of clinical operations reviewed and issued 14 recommendations that are attributable to the Facility Director, Chief of Staff, Nurse Executive, and Assistant Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value • Review of Ongoing Professional Practice Evaluation data(2) Medication Management: Anticoagulation Therapy• Employee competency assessments (3) Coordination of Care: Inter-Facility Transfers• Documentation of informed consent and patient stability for transfer• Resident supervision• Communication with accepting facility(4) Environment of Care• General safety and cleanliness• Infection prevention risk assessment• Dirty and used equipment storage• Panic alarm and security surveillance television system testing (5) Long-Term Care: Community Nursing Home Oversight• Oversight committee membership • Program integration• Cyclical clinical visits

The VA OIG conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the James J. Peters VA Medical Center (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; and High-Risk Processes: Moderate Sedation. OIG also provided crime awareness briefings to 162 employees. The facility had generally stable executive leadership and active engagement with employees and patients to maintain high satisfaction scores. Organizational leadership supported patient safety, quality care, and other positive outcomes. 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. OIG noted findings in the 5 areas of clinical operations reviewed and issued 15 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value • Frequency of Quality Executive Board meetings• Review of credentialing and privileging data• Utilization management reviews and documentation(2) Medication Management: Anticoagulation Therapy• Use of quality assurance data (3) Coordination of Care: Inter-Facility Transfers• Transfer data reporting and analysis• Documentation for acute patient transfers to other facilities(4) Environment of Care• Environment of Care rounds attendance• Panic alarm and security surveillance television system testing• Interdisciplinary Safety Inspection Team training(5) High-Risk Processes: Moderate Sedation• Monitoring of moderate sedation outcome data• Performance of history and physical examinations and pre-sedation assessments• Clinical staff training

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