Inside Oversight VA OIG

In this episode of Inside Oversight, Nicole Maxey, a nurse consultant with the Office of Healthcare Inspections, discusses the VA OIG’s evaluation of the transition of clinical care for service members with opioid use disorder from the Department of Defense to the Veterans Health Administration. Nicole describes deficiencies in documenting patients’ opioid use disorder, as well as the barriers faced by healthcare providers accessing records, during the transition.  
“We want to make sure that all providers are aware of [opioid use disorder] to ensure that this vulnerable veteran population gets the care they need. Even if we prevent one death, this report will have reached the people we really wanted it to.” – Nicole Maxey 
 
Related Report:  
Review of Clinical Care Transition from the Department of Defense to the Veterans Health Administration for Service Members with Opioid Use Disorder
 

In this podcast episode of Inside Oversight, Erica Taylor, a health system specialist with the Office of Healthcare Inspections, discusses a healthcare inspection at the West Palm Beach VA Healthcare System in Florida that assessed allegations related to a patient’s cancer care coordination.  
 
“Over the years, the OIG has published many reports detailing issues related to appointment scheduling with community providers and delays in VA getting clinical information back from community providers. There have been several prior reports that highlight failures in coordinating community care for services.” – Erica Taylor
Related Report: 
Inadequate Coordination of Care for a Patient at the West Palm Beach VA Healthcare System in Florida

In this episode of Inside Oversight, Amanda Newton, an associate director with the Office of Healthcare Inspections, discusses a report on deficiencies with the Patient Safety Program at the Tuscaloosa VA Medical Center in Alabama. She shares how a lack of resources, supervisory engagement, and failure of facility leaders to act impacted the medical center’s culture of safety. Find this episode at the VA OIG’s podcast page or where you normally listen to podcasts.
 
“I would just add that this report details deficiencies at just one VA medical center. I think it would serve as a cautionary tale to other facilities throughout VHA. There are lessons learned here that we can certainly apply to other facilities. I really hope that other facilities’ staff and other facilities’ leaders can take the information here and use these lessons to ensure the strength of their patient safety program.” – Amanda Newton
Related Report: 
Deficiencies in the Patient Safety Program and Oversight Provided by Facility and VISN Leaders at the Tuscaloosa VA Medical Center in Alabama 

In this episode, Dr. Amber Singh, an associate director with the VA OIG’s mental health team within the Office of Healthcare Inspections, discusses a published report on VHA’s Intimate Partner Violence Assistance Program. Her team conducted a national review of the program to evaluate implementation status and identify perceived barriers to compliance by surveying program coordinators and leaders. She shares how the team found over half of VHA facilities did not have the required program protocol, which may contribute to leader and staff confusion and lack of knowledge about the program’s roles, responsibilities, process, and procedures.
“Fifteen of the 25 coordinators we interviewed described screening as one of the most challenging aspects of IPVAP implementation. They explained to us that screening being optional and lack of staff buy-in due to other priorities in clinical care were barriers to routine screening. Some coordinators suggested screening should be considered.” – Dr. Amber Singh
Related Report: Intimate Partner Violence Assistance Program Implementation Status and Barriers to Compliance

In this episode, Dr. Wanda Hunt, a VA OIG healthcare systems specialist, discusses a recently published report on VHA’s Intensive Community Mental Health Recovery Programs. The report examined the visit frequency for veterans enrolled in these programs between April 2019 and March 2021.

In this episode, Susan Tostenrude, a director within the Office of Healthcare Inspections, discusses the report, Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a Community Living Center at VA Illiana Health Care System in Danville, Illinois.