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