Federal Reports

This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the outpatient care provided at the VA Texas Valley Coastal Bend Health Care System in Harlingen. This evaluation focused on key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of careThe OIG did not issue any recommendations.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the West Palm Beach VA Healthcare System in Florida to assess allegations related to a patient’s cancer care coordination.The OIG did not substantiate that the primary care provider failed to coordinate care or that the pulmonologist failed to surveil the patient’s care. However, the pulmonologist did not inform the patient about the results of a computerized tomography (CT) scan or use the mandatory appointment scheduling process as required. Attempts were made by the pulmonologist to discuss the CT scan results with the patient, but the patient canceled the appointments. The pulmonologist responded to the patient’s rescheduling requests by entering notes in the patients’ electronic health record (EHR) instead of using the required appointment scheduling process, resulting in the patient not being seen by the pulmonologist.The OIG identified concerns regarding community care coordination after a facility chiropractor did not follow up on a community care chiropractor’s recommendation for a magnetic resonance imaging (MRI). After meeting with the patient for complaints of back pain, the community care chiropractor’s note and documented recommendation for an MRI were scanned into the patient’s EHR. Although the facility chiropractor acknowledged the note through signature, the OIG found no documented evidence that the facility chiropractor took action to determine if an MRI was needed. The patient received an MRI months later that showed a fracture, likely related to underlying metastatic disease.The OIG made three recommendations to the Facility Director to ensure that pulmonology providers communicate test results to patients and utilize the appropriate appointment scheduling processes, and to ensure that chiropractor providers review community care notes and takes actions as needed.

The Government Accountability Office defines training as educational programs of instruction in professional, technical, or other fields that are, or will be, related to the employee’s job responsibilities. TVA’s Regulatory and Corporate Training and Support organization aims to (1) create and maintain safety and environmental training that ensures employees are trained to regulatory requirements, (2) support the job assessment process to ensure employees are assigned the training they need to perform their jobs, and (3) create and support the corporate and technical training that enables individual professional and technical development. Due to the importance of training and development programs in contributing to improved organizational performance and enhanced employee skills and competencies, we conducted an evaluation of TVA’s training and development processes. We found the process for identifying training needs was generally effective; however, we found some of TVA’s training processes were not effective and needed improvement. Specifically, we found (1) not all individuals were assigned the appropriate training, and (2) the effectiveness of training was not always being measured.