Federal Reports

What OIG Evaluated: 

The Office of the Inspector General (OIG) initiated a  follow-up evaluation on the Library’s “not on shelf”  (NOS) rate which refers to when materials requested  by users cannot be found by the Library. The evaluation’s objectives were to determine the NOS rate and the timeliness and quality of the library’s retrieval service. 

What OIG Found: 
- The Not on Shelf rate has remained largely unchanged since 2011.
- Collection items were delivered promptly.
- Utilizing customer service standards is necessary to make the Collection Management Divisions material retrieval service more user centered.
- Documenting responsibilities is necessary to improve the quality of the material retrieval service.

What OIG Recommends: 
1. Perform an assessment to determine the  desired quality of the Collection Management Division  material retrieval  service and, accordingly, establish customer  service standards.
2. Establish performance measures to begin  measuring performance against the  customer standards for the Collection Management Division material  retrieval service.
3. Develop and implement via documented  policies and procedures Collection Management Division staff  responsibilities associated with: a) following  up on not on shelf items through the Collection Management Division quality 
assurance process; b) ensuring reliable  delivery of status updates via emails; and c)  monitoring the condition of collection items. 

We engaged with an independent public accounting (IPA) firm to audit DIA's FY 2023 financial statements. We evaluated the reliability of data supporting the financial statements, determined the reasonableness of the statements produced, and examined disclosures in accordance with applicable guidance.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess the quality of care provided during a patient’s hospitalization, which ended with the patient’s death at the Lt. Col. Luke Weathers, Jr. VA Medical Center (facility) in Memphis, Tennessee. The OIG also evaluated facility leaders’ response to the patient’s care.A telemetry technician’s failure to follow a series of communications within the time frame established in the facility’s cardiac telemetry monitoring policy delayed initiating a blue alert, which may have affected the patient’s outcome. A charge nurse’s failure to assign a nurse to care for the patient or provide accurate nursing assignments to the telemetry technician may have also contributed to the delay. Additionally, an intensive care unit fellow did not document a response to a critical care consult and did not recall the patient, rendering the OIG unable to determine the clinical decision-making rationale.Facility leaders’ factfinding and root cause analysis reviews of the patient’s care were not thorough, which hindered identification of systemic and causal factors. Contributing factors included a nursing leader who did not issue an authorization letter to provide the factfinding investigator guidance on the focus of the review, and the root cause analysis team who did not interview some staff directly involved with the patient event, as required.The OIG made five recommendations to the Facility Director related to compliance with the cardiac telemetry monitoring policy, making and communicating nursing assignments, documenting critical care consults, conducting factfindings and root cause analyses, and consideration of another root cause analysis.