Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Northport VA Medical Center and multiple outpatient clinics in New York. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.Medical center leaders had worked together for almost five months at the time of the virtual inspection. Employee satisfaction survey scores for the medical center were lower than VHA averages, but scores for the Director were consistently higher than those for VHA and the medical center. Outpatient satisfaction survey results were generally higher than VHA averages but revealed opportunities to improve specialty care experiences for female veterans. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Medical center leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.The OIG issued five recommendations for improvement in four areas:(1) Quality, Safety, and Value• Peer review of deaths within 24 hours(2) Registered Nurse Credentialing• Primary source verification(3) Care Coordination• Nurse-to-nurse communication(4) High-Risk Processes• Disruptive behavior committee meeting attendance• Staff training

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA New Jersey Health Care System in East Orange. The inspection covered key clinical and administrative processes associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the inspection, the Director had served in the role since 2017 and some other leaders had been in their positions for over a year. Employee satisfaction survey data revealed opportunities for the Associate Director for Patient Care Services and Associate Director to improve perceptions of leadership and the workplace. Patient experience survey results indicated that males were generally satisfied with their primary care compared to VHA averages. Outpatient survey scores for females were lower than VHA averages. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Leaders were knowledgeable within their scope of responsibilities about VHA data and factors contributing to poor performance on specific Strategic Analytics for Improvement and Learning measures.The OIG issued eight recommendations for improvement in four areas:(1) Quality, Safety, and Value• Systems redesign and improvement coordinator meeting participation• Peer review processes• Surgical work group meetings(2) Registered Nurse Credentialing• Primary source verification(3) Care Coordination• Patient transfer monitoring and evaluation(4) High-Risk Processes• Disruptive behavior committee meeting attendance

The U.S. Postal Service developed an overarching Continuity of Operations (COOP) plan that allows essential business functions to continue when there is a disruption of normal operations. In support of that plan, the Postal Service developed the Retail Systems COOP (Plan) to provide a methodology for continuing retail operations in the event of a complete Retail Systems Software (RSS) system failure or power or network outage. The Plan ensures that field retail operations provides a limited scope of products and services with minimal customer service impact if retail systems automated functions become unavailable. In fiscal year (FY) 2021 post office retail revenue was over $13 billion.

This management alert presents issues the U.S. Postal Service Office of Inspector General (OIG) identified during the State of Cybersecurity audit (Project Number 21-205). Our objective is to notify Postal Service management of risks associated with security control deficiencies identified during the Assessment & Authorization (A&A) process that have not been mitigated.

This joint audit led by the DoD OIG examined actions taken by the DoD and VA regarding the Cerner Millennium electronic health record (EHR) system being deployed throughout VA and DoD. The audit assessed internal controls and compliance with legal requirements, as well as actions by DoD, VA, and their joint Federal Electronic Health Record Modernization (FEHRM) Program Office to help ensure that health care providers serving veterans can access a patient’s complete EHR. The audit focused on whether those actions would achieve interoperability between DoD, VA, and external health care providers. The joint audit found that DoD and VA took some actions to achieve system interoperability, but there are remaining challenges. DoD and VA did not consistently migrate information from legacy systems into Cerner Millennium to create a single, complete patient EHR; develop interfaces from all medical devices to the system; or ensure users were granted access to Cerner Millennium only for information needed for their duties. A contributing factor for these deficiencies was that the FEHRM Program Office did not develop a clear plan to achieve full interoperability or actively manage the program’s success. The audit report recommends that DoD and VA review FEHRM’s actions and direct the program office to comply with its charter and applicable laws. The FEHRM should also coordinate with DoD and VA on implementing recommendations that include (1) determining the type of health care information that constitutes a complete EHR; (2) implementing a plan for accurately migrating legacy health care information; (3) create medical device interfaces to directly transfer health care information to Cerner Millennium; and (4) implementing a plan to modify system user roles to ensure their access is restricted to only information needed to perform their duties.