In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses deficiencies in the quality of emergency department care for a veteran who died by suicide at the John Cochran Division of the St. Louis Healthcare System in Missouri. This edition also includes highlights of the VA OIG’s work from July 2023.“Approximately 10 minutes later is when the staff person finds the patient unresponsive in the exam room with a ligature around his neck. A code was called, meaning a code blue so that all emergency staff would present to that room, and they tried to resuscitate the patient, but that was unsuccessful, and he was pronounced dead about 10 to 15 minutes later.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related ReportDeficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses missteps in the care of a veteran who eventually committed suicide on the grounds of the Aiken Community Based Outpatient Clinic, part of the Charlie Norwood VA Medical Center in Augusta, Georgia. This edition also includes highlights of the VA OIG’s work from June 2023.       “In VA you're assigned a primary care provider called your PCP, that, in theory, should be the main provider you see. That's where all of your referrals start for specialty care, and that's how you gain continuity of care. Unfortunately, with this veteran he saw one provider, and then the next appointment saw a different provider, and then the third appointment saw a third provider.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director  Related Report:Deficient Care of a Patient Who Died by Suicide and Facility Leaders’ Response at the Charlie Norwood VA Medical Center in Augusta, Georgia

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses how she and her team triage healthcare-related hotline inquiries. She shares how concerns over the management of a patient safety program led to an inspection and subsequent report at the Tuscaloosa VA Medical Center in Alabama. This edition also includes highlights of the VA OIG’s work from May 2023.       “I think the takeaway for all of this is VHA needs to ensure involvement of all staff in the patient safety program at the respective facilities, but also ensure oversight of those safety patient safety programs. The oversight is just as important as participation when trying to ensure that the facility has opportunities to identify system vulnerabilities and then address those concerns with the hopes of preventing future patient safety events from occurring.” Trina Rollins, Director of Hotline Coordination, Office of Healthcare InspectionsRelated Publications: Deficiencies in the Patient Safety Program and Oversight Provided by Facility and VISN Leaders at the Tuscaloosa VA Medical Center in Alabama Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center in Alabama (September 2, 2020) Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center, Alabama (September 27, 2019)

IG Michael J. Missal discusses the VA OIG's 89th Semiannual Report to Congress covering the reporting period of October 1, 2022, to March 31, 2023. Plus oversight highlights from the VA OIG's work in March and April of 2023. For this six-month period, the VA OIG identified more than $401 million in monetary impact for a return on investment of $4 for every dollar spent on oversight. These figures do not include the inestimable value of the healthcare oversight work completed to advance patient safety and quality care. During this six-month period, the Office of Investigations opened 222 cases and closed 217 (most of which were opened in prior periods), with efforts leading to 122 arrests. The OIG hotline received and triaged 15,526 contacts to help identify wrongdoing and address concerns with VA activities. Collectively, the work during this period resulted in 595 administrative sanctions and actions. The Office of Audits and Evaluations (OAE) produced 52 work products, including one VA management advisory memorandum that highlighted concerns requiring VA’s prompt attention, 19 oversight reports, and 32 preaward and postaward contract reviews to help VA obtain fair and reasonable pricing on products and services. OAE reports for the six-month period resulted in 128 recommendations. The Office of Special Reviews issued two publications, including an administrative investigation that focused on VHA employing four people who had been previously excluded from holding a paid position in a federal healthcare program. The Office of Healthcare Inspections (OHI) focused on leadership and organizational risks, suicide risk reduction, and care coordination. OHI published 14 healthcare inspection reports; two national healthcare reviews; 11 Comprehensive Healthcare Inspection Program (CHIP) reports, including four CHIP summary reports; two Vet Center Inspection Program reports; and two Care in the Community reports.   Featured Publications:Stronger Controls Help Ensure People Barred from Paid Federal Healthcare Jobs Do Not Work for VHAVeterans Are Still Being Required to Attend Unwarranted Medical Reexaminations for Disability BenefitsDeficiencies in Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning for Patients with Suicidal Behaviors by FirearmsOpioid Safety at the VA Northern California Health Care System in Mather 

In this episode, host Fred Baker talks with Dr. Julie Kroviak, the principal deputy assistant inspector general of the VA OIG’s Office of Healthcare Inspections, about changes to how cyclical healthcare reviews are conducted. Dr. Kroviak explains how her teams are reworking the Comprehensive Healthcare Inspection Program cyclical reports to provide more information on the veteran communities being served by VA medical facilities. Additionally, she shares how, for the first time, the VA OIG will start reviewing VA mental health programs cyclically.             “We're going to start with a glimpse of the community that the facility operates in, and that's totally new. We've never done anything like that but giving the reader a sense of who's living in this community, what's the education level, what's the income level, the disease burden, active duty and veteran populations, all of these [factors] sort of really influence how care is delivered, and we want to present that in a reader-friendly kind of glimpse so you can understand what's influencing care and the veterans served in that community.” – Dr. Julie Kroviak