Inside Oversight is an official podcast of the Department of Veteran Affairs, Office of Inspector General. Each episode examines in detail some of our more nuanced oversight reporting. To understand the complexities of the topics, we talk with the report authors to gain insight into how the team conducted its work, what it found, and the impact on veterans and the public. Visit the VA OIG website for recently published reports.
Nurse Consultant Shares Challenges for Veterans with Opioid Use Disorder Transitioning from DoD to VHA
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 (https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.va.gov%2Foig%2Fpublications%2Freport-summary.asp%3Fid%3D5301&data=05%7C01%7C%7C049023dd90da4131f77908dbaa3b85d5%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638290944852958942%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=8iHQRZP1YmEAEiQfJIqS5sV1N5miohynXZFf%2FmsTLjY%3D&reserved=0)
31 Jul 2023
Health System Specialist Discusses Inadequate Care at the West Palm Beach VA Facility
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 (https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.va.gov%2Foig%2Fpublications%2Freport-summary.asp%3Fid%3D5262&data=05%7C01%7C%7Cc87eeccdd33d4f590ceb08db91ddd3cd%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638264154142885046%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=%2F0kG%2Bi%2FDZI5p9VczW%2FwWmjJV684fJhDQoxcChOYpxwU%3D&reserved=0)
5 Jul 2023
VA OIG Safety Expert Discusses Deficiencies with Patient Safety at the Tuscaloosa VAMC
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 (https://www.va.gov/oig/publications/report-summary.asp?id=5251)
21 Mar 2023
Intimate Partner Violence Assistance Program Implementation Status and Barriers to Compliance
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 (https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.va.gov%2Foig%2Fpublications%2Freport-summary.asp%3Fid%3D5205&data=05%7C01%7C%7C67c1a32ec3c54610300f08db298690f3%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638149430158002308%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=ORkMZysmyCgub5E5V82sqIAgJVnNGJ9tvFwIVnytRBs%3D&reserved=0)
6 Feb 2023
VA OIG Healthcare Systems Specialist Discusses New Report on Intensive Community Mental Health Recovery Programs
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.
8 Sept 2022
Healthcare Inspector Discusses COVID-19 Outbreak at a Community Living Center in Illinois
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.
1 Sept 2022
Healthcare Inspectors Discuss Issues Related to a Patient's Quality of Care in Ohio's Chillicothe VAMC
In this episode, healthcare inspectors discuss the report Failure to Follow a Consult Process Resulting in Undocumented Patient Care at the Chillicothe VA Medical Center in Ohio.
30 Aug 2022
Director of Community Care Discusses VISN 23's Healthcare Inspection
In this episode, the VA OIG's director of community care discusses a healthcare inspection of VISN 23, which includes sites in Iowa, Minnesota, Nebraska, N. Dakota, S. Dakota, and parts of Illinois, Kansas, Missouri, Wisconsin, and Wyoming. VISN 23 serves over 440,000 vets.
18 Aug 2022
VA OIG Healthcare Inspectors Discuss the Vet Center Inspection Program
VA OIG healthcare inspectors share the history of vet centers, OIG’s oversight of vet center operations, and the findings from the first five VCIP reports published.
14 Jul 2022
Audit Manager Discusses OIG Report on VHA's Suicide Prevention Coordinators
VA OIG Audit Manager discusses the report, Suicide Prevention Coordinators Need Improved Training, Guidance, and Oversight, published on June 6, 2022.
11 May 2022
Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient’s Death by Suicide
In this episode, two mental health experts with the VA OIG's Office of Healthcare Inspections discuss a report that focused on deficiencies with mental healthcare coordination and processes prior to a patient’s death by suicide at the VA hospital in Columbia, Missouri.
11 May 2022
Challenges for Military Sexual Trauma Coordinators and Culture of Safety Considerations
In this episode, two directors with the VA OIG's Office of Healthcare Inspections discuss a report that focused on challenges for military sexual trauma coordinators and the culture of safety for patients requesting related care.
11 May 2022
VHA’s Virtual Primary Care Response to the COVID-19 Pandemic
In this episode, two associate directors with VA OIG's Office of Healthcare Inspections discuss a report that focused on the Veterans Health Administration’s virtual primary care response to the COVID-19 pandemic from February 7, 2020 through June 16, 2020.
11 May 2022
VA OIG Auditors Discuss Improper Payments for Community Acupuncture and Chiropractic Services and Risks to Evaluation and Management Services
VA OIG senior auditors discuss two related reports on improper payments for community acupuncture and chiropractic services and overall risks to evaluation and management services.
7 Apr 2022
VA OIG Director Discusses VHA’s Methodologies for Calculating and Presenting Wait Times
Daniel Morris, a director within the Office of Audits and Evaluations, discusses VA OIG’s recent report, Concerns with Consistency and Transparency in the Calculation and Disclosure of Patient Wait Time Data, published on April 7, 2022.
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