All Reports

Assess electronic health record major performance incident data needs and contractually commit to real-time data sharing that will provide greater awareness of system operations.

Develop a formal procedure for verifying performance metrics and associated credits to ensure the department receives the remedies it is due under the contract.

Update the process for prioritizing major performance incidents to ensure that notification and resolution occur in a consistent manner.

Develop effective notification and resolution metrics that consistently capture results for all major performance incidents, regardless of the owner, and enforce them.

Identify the information needed in post-resolution reports, such as corrective and preventative actions, and require the contractor to consistently collect, verify, and report that information as a contract deliverable.

Develop a plan to ensure all clinicians are familiar with the national downtime procedures.

Identify the appropriate backup system and develop a training strategy to ensure clinicians can use the system during downtime.

Assess facilities’ patient safety reports identified during this audit to determine if additional actions need to be taken and, if so, provide an action plan.

Develop a mechanism to better identify major performance incidents and negative patient outcomes and provide a plan to prioritize and address their causes.

Establish a plan to use VA’s cost accounting system information to identify alternative ways to reduce costs, enhance efficiency, and inform business decisions as identified by VA financial policy. This could include implementing federal financial accounting standard practices to use cost information for performance measurement, budgeting, cost control, and making economic choices.

Consider requiring that the managerial cost accounting team review the Intermediate Product Cost Outlier report to identify cost outliers that may occur at the healthcare system.

Ensure healthcare services are completing monthly data validation memos for their managerial cost accounting data.

Ensure that healthcare system staff follow policy requirements; and that fiscal staff conduct reviews on all open obligations as required by VA Financial Policy, vol. 2, chap. 5, “Obligations” (2020), updated May 2023.

Ensure that healthcare contracting staff follow federal acquisition regulations when terminating contracts for convenience to the government.

Establish controls to ensure cardholders comply with record retention requirements, confirm approving officials and cardholders review purchases for VA policy compliance, and ensure contracting is used when it is in the best interest of the government.

Require cardholders to submit a request for ratification for any unauthorized commitments identified.

Develop and implement a plan to ensure data accuracy and reliability in the Generic Inventory Package.

Develop and maintain a standardized training program for logistics and clinical staff on the proper recording of items as they are removed from primary and secondary inventory points.

Ensure that MSPV facility-level contracting officer’s representatives are appointed and designated properly and perform all required duties according to the scope and limitation of the designee’s authority.

Reevaluate the risk determination for the Veterans Health Administration Geographic Information System and determine if the system should be set to a security categorization level of “moderate” based on the personally identifiable information and other sensitive data maintained in the system.

Ensure the Data Breach Response Service director instructs staff associated with the incident response process that each security and privacy incident that occurs must be captured on a separate Privacy Security Events Tracking System ticket, confirms document investigation details are accurate, and reassesses whether the security incidents were a breach.

Request that the contractor perform a self-audit of local VA claims.

Verify that the contractor has completed the process of refunding local VA claims.

Establish policies and procedures for Grant and Per Diem liaisons to obtain reliable discharge information from grantees when veterans exit from the Grant and Per Diem Program.

Implement controls, including enhanced medical facility and grantee guidance and training, to ensure grantee files and VA medical record documentation of veteran housing outcomes are consistent with Homeless Operations, Management, and Evaluation System data definitions and support the data in the Homeless Operations, Management, and Evaluation System.

Implement controls, such as quality reviews, to ensure Homeless Operations, Management, and Evaluation System outcome data are supported by and consistent with veteran medical records and grantee files.

Confirm VA has resumed submitting biweekly reports and, therefore, has submitted reports from June 2023 to present as required by the VA Transparency & Trust Act of 2021.

Confirm that the American Rescue Plan Act of 2021 section 8002 quarterly reports are submitted to Congress within the time frame established on the Consolidated Appropriations Acts of 2022 and 2023, which is no later than 30 days after the end of each fiscal quarter.

Coordinate with administration and staff office chief financial officers to ensure that the finance office staff responsible for the management of open obligations know and understand VA financial policy requirements for the review of open obligations included in quarterly obligation reports.

Ensure that annual reports to Congress include the steps VA is taking to improve the onboard timeline for facilities for which the duration of the onboarding process exceeds the metrics laid out in the Veterans Health Administration’s time-to-hire model, or successor model, as required by section 3008(b) of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020.

Track facilities’ supply chain personnel vacancies as part of the quality control reviews and take appropriate action.

Develop guidelines that define when facility supply chain management problems require additional interventions and then routinely identify them for network director action.

Ensure facility and network directors work with the Procurement and Logistics Office on a plan to identify resources and milestones to resolve identified supply chain management problems for identified facilities.

Direct the program office to develop a process to provide resources when needed to help networks and facilities resolve persistent supply chain management deficiencies, including those identified in this report.

Continue Procurement and Logistics Office efforts to automate tracking that will accurately capture and monitor all quality control review results, corrective action plans, and implementation of those plans.

Update the Procurement and Logistics Office audits of the quality control program to apply risk‑based sampling, evaluate action plan sufficiency and implementation, and use the results to continuously improve quality control review guidance and requirements.

Establish a plan to use VA’s cost accounting system information to identify alternative ways to reduce costs, enhance efficiency, and inform business decisions as identified by VA financial policy.

Consider a plan to align VA Pittsburgh Healthcare System financial management practices with federal financial accounting standard practices, which could include using cost information for performance measurement, budgeting, cost control, and making economic decisions.

Ensure requesting offices are trained to effectively communicate status of open obligations in a timely manner so healthcare system finance staff can comply with VA Financial Policy, vol. 2, chap. 5, “Obligation.” by ensuring monthly that open obligations balances are valid and should remain open or are closed in a timely manner.

Establish an escalation process to notify the appropriate leaders if the requesting office does not provide a response to the finance office’s monthly request for status of outstanding obligations.

Establish controls to confirm approving officials and cardholders review purchases for VA policy compliance, ensuring purchases are not being split and that strategic sourcing is pursued for ongoing or repetitive purchases.

Ensure supply chain managers implement a plan to detect and correct data validity issues within inventory systems.

Improve vulnerability management processes to ensure plans of action and milestones are created for vulnerabilities that cannot be mitigated within OIT timelines.

Implement a more effective system life-cycle process to ensure network devices are running operating systems that are configured to approved baselines and free of vulnerabilities.

Implement a process to verify that when employees are terminated, all their accounts are disabled.

Ensure network segmentation controls are applied to all network segments with special-purpose systems.

Implement a process to retain database logs for a period consistent with VA’s record retention policy.

Instruct the Office of Finance to review the $14 million retained by the medical centers to ensure these funds were, or will be, spent in accordance with all applicable VA policies and federal laws.

Require the Office of Finance to strengthen controls over designated specific purpose funds so that Veterans Integrated Service Network chief financial officers can account for all the distributed funds and make certain that the funds are used for the intended purpose.

Define the roles and responsibilities of the appropriate assistant under secretaries, program office staff, and regional and medical center staff in the implementation and monitoring of the substance use disorder hiring initiative and ensure the relative priority of the initiative is communicated; hiring progress is monitored; possible hiring challenges are addressed to the extent possible; and actions are taken as needed to meet the goals of the hiring initiative.

Establish internal controls to help ensure the healthcare system monitors the Medical/Surgical Prime Vendor product list for updates and completes the item conversion process

Ensure that prime vendor contract performance issues are routinely reported to the Medical Supplies Program Office and the Strategic Acquisition Center using established Veterans Health Administration reporting tools.

In coordination with the Strategic Acquisition Center, submit ratifications for any unauthorized commitments following the Federal Acquisition Regulation.

Ensure that the facility-level contracting officer’s representative and ordering officers are appointed and delegated properly and perform all required duties according to the scope and limitation of the designee’s authority.

Establish internal controls to help ensure the healthcare system submits national contract requests for waiver and justifications prior to purchasing available product list items from nonmandatory procurement instruments.

Ensure cardholders obtain a proper prior approval and maintain segregation of duties, and ensure that cardholders and approving officials perform prompt purchase card reconciliations as required by VA financial policy.

Develop formalized processes and controls to ensure approving officials, cardholders, and the agency contracting office review repetitive open market purchases of goods and services and obtain contracts when it is determined to be in the best interest of the government.

In coordination with the Strategic Acquisition Center, submit a ratification for an unauthorized commitment following the Federal Acquisition Regulation.

Develop formalized processes for monitoring and achieving efficiency targets and using available pharmacy data to make business decisions.

Develop and implement a plan to increase inventory turnover to meet or exceed the VHA-recommended level, and complete monthly B09 reconciliations consistently to ensure discrepancies are corrected in a timely manner.

Establish measures to improve compliance with the VA directive to avoid end-of-year pharmaceutical purchases.

The VA Black Hills Health Care System Director ensures that summary suspensions and related privileging actions are conducted in accordance with Veterans Health Administration policy, and monitors for compliance.

The VA Black Hills Health Care System Director in conjunction with facility leaders and surgical service leaders, ensures a focused clinical care review is completed of the care provided by the subject provider according to Veterans Health Administration policy, and takes action as warranted.

The VA Black Hills Health Care System Director, in conjunction with the National Center for Patient Safety, evaluates the patient safety event reporting processes, identifies deficiencies, and takes action as warranted to ensure compliance with entering adverse events or close calls into the Joint Patient Safety Reporting system.