Veteran Oversight Now

Fred Baker
Welcome back to another podcast episode of Veteran Oversight Now, an official podcast of the VA Office of Inspector General. I'm your host, Fred Baker. Each month on this podcast, we'll bring you highlights of the OIG's recent oversight activities and interview key stakeholders in the office's critical work for veterans.
Joining me today is Dr. Julie Kroviak, the Principal Deputy Assistant Inspector General for the office of Healthcare Inspections. Dr. Kroviak is not new to the podcast. She joined the program in February of last year to discuss the new Vet Center Inspection Program, and was on the program again in September to discuss staffing shortages at VHA. If you haven’t heard those programs, I encourage you to go to our podcast webpage or anywhere you get your podcasts and give them a listen.
Welcome, Dr. Kroviak.
Dr. Kroviak
Thank you, Fred.
Fred Baker
Dr. Kroviak, we're here to talk about some proactive changes in healthcare's oversight. But before we get to that, give the listeners a general overview of the primary oversight products your directorate produces.
Dr. Kroviak
Yeah, I think most people, certainly our staff, are familiar that OHI publishes hotlines and national reviews, and we have some specialty teams that focus on really important topics specific to mental health, women's health, and community care. We put out about 60 to 65 of these reports annually, and they target very specific issues that are usually prompted by credible allegations that made us want to look deeper because we thought they had the chance to influence care across the system. But then we have our proactive cyclical reviews. So, the comprehensive healthcare inspection program—we call them CHIPs—reviews of the VISN, and then our newer vet center reviews.
And we're also piloting a new mental health cyclical review, and we hope to get those teams on the road later this spring. These reviews typically focus on health care topics that are really important to the populations that are being served. So, you know, for vet centers, we're looking at issues that clients who come into the vet center, what they need and how that's being delivered. And for reviews that the CHIP, for the CHIP we're looking at facility care level. So, inefficiencies and things that negatively influence care, but really looking to make sure VHA is following their own policies and directives.
Fred Baker
So, it's my understanding and what we've come here to talk about today is that there are some upcoming changes to the approach of some of your work. Which products are changing and how are they going to change?
Dr. Kroviak
And so, the change leading the charge are the CHIPs. So those are the facility-level reviews, and those have been designed to be a traditional compliance-based review. And the topics, again, are specific to trends that we're noting in other products or trends in health care in general. And we conduct those with facility visits, data review, and interviews of staff. We pick topics for those reviews that are critical to making sure that operations are safe and efficient. And we rotate subtopics that will hit on issues that really matter in the current time of health care or related, like I said, to other products that we're looking at that have hit on this repeatedly that we think we need to look at it across the system.
Fred Baker
And these have been pretty critical to your oversight work. Correct? Stakeholders in VHA seem to rely on these reports.
Dr. Kroviak
Very much so. You know, we're never welcomed as friends there, but that's the nature of oversight. But it is really important. We've got a presence on site, we're interacting with staff, we're reviewing data.
We basically hand them a roadmap of where they need to focus. But it's always been very heavy on compliance, and we know that means we're missing some good local stories. You know, Boston's not Topeka, Topeka's, not Grand Junction, but when you really take a strict compliance-based approach, you're going to miss a lot of the local context.
CHIPs, over the past couple of years, they have been doing more in-depth leadership interviews. So, the change has been brewing because we've been getting a lot of good, interesting information for those interviews that we'd like to capture more so. COVID also highlighted some of the challenges and the resiliencies associated with certain areas in VHA and across health care. So that gave us more impetus to provide some local context to our stories.
Fred Baker
Before we talk a little bit more about how the product itself will change, this also means that the teams will change the way they approach this work. How will that change?
Dr. Kroviak
So, everything's going to be different, but the staff performing these reviews. And they are incredibly motivated to really get out there and do this work in a different way. 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 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.
Fred Baker
If these products have been, you know, valuable as oversight products and stakeholders have come to rely on them, why the change? Why rethink it?
Dr. Kroviak
So, health care is nothing but a dynamic set of activities that need to be coordinated. It's a limited resource, so every penny has to be scrutinized to make sure that it yields the highest quality. Change is the only constant in health care, and we put repeat findings in reports. Does that mean the system is not responding or maybe oversight isn't responding to the dynamic way in which health care is evolving?
I get the resistance. You know, there's always ‘This is how we always do it,’ or ‘This is our bread and butter,’ but we have to lose that behavior in our oversight approach. If health care's always changing and it's always working towards better outcomes and improving efficiencies, we have to do the same.
Fred Baker
Okay. So, let's talk specifics. These reviews have kind of centered around identified topics. Now you're calling them domains. What's different and what's that look like?
Dr. Kroviak
So, we're really changing the culture of how we do the work, too. You'll notice there'll be some name changes, and I think the title's going to change too. But domains really imply what we were doing before in terms of choosing a topic. We’re just calling them domains now.
And we'll have subtopics within those domains as well. As an example, environment of care, that really isn't changing in terms of the title. How we're going to look at that is a little bit different because even in this predictable component of the oversight tool, we want to describe a connection between the safety elements we’re inspecting and the actual patient care. So, why are repeat findings happening? Why are work orders not completed from previous findings? What would that mean to a patient getting care in that particular setting? We want to build and bridge that connection.
Fred Baker
So, environment of care you have in patient safety. What are some of the other domains?
Dr. Kroviak
So, the final domains get really specific to challenges that are unique to providing health care to veterans. I have an incredible enthusiasm for that as a former VA provider. I like to think about how these reports could have supported me in that role.
I also feel these can push health care oversight into brand new territories, territories that can change how our stakeholders use us and actually learn to rely on our participation. So, starting with my passion, which is primary care, we'll have a whole domain that focuses just on primary care.
VHA uses this PACT model to deliver care to enrolled veterans and PACT is a primary aligned. sorry, Patient Aligned Care Team. The goal is to give continuity of care through a team relationship so the veteran communicates and coordinates with their primary care team. This is the hub of everything for a veteran to get access into the system. So not just primary care, but “Hey, what happened to my dermatology appointment? I need this paperwork completed. They sent me out for community care, but I haven't heard from that provider yet about an appointment.”
Primary care is the pulse of the veterans’ care, but also of the facility. And it has to have a strong rhythm to meet these veterans and their multi-disciplinary needs.
Fred Baker
And you seem to be hitting on the idea that in certain aspects, health care for veterans is inherently different. Providing health care for veterans is inherently different. Am I understanding that correctly?
Dr. Kroviak
Absolutely. So, we know veterans have unique military experiences that create unique needs and the system has to be responsive to that. VHA has customized tools and multidisciplinary resources, almost imagine triggers that initiate a cascade of evidence-based supports to veterans, particularly in high-risk groups, whether it's a high-risk socioeconomic group or a high-risk clinical group. Backstage, we call these safety nets.
So, the next domain right now we're calling it that veterans centered
safety nets. So, think ‘How is a facility use utilizing resources that are foundational to veterans care?’ We call them social determinants of health, and they do influence the outcomes for all patients. Let's talk about social work, high risk, mental health, homelessness, everything that is in place to take care of the most vulnerable population.
Fred Baker
Electronic health record modernization and community care. Those are frequent topics for which our reports are showing massive change in how veterans are going to receive their care in the future. Will these new cyclical reviews touch on those?
Dr. Kroviak
So, I can't imagine how they won't. We don't have domains specific to them. But if I could introduce now this domain that we're calling culture. It's the culture of a facility. How do we explore this? We're going to ask two basic questions. Do I want to work here and do I want to receive care here?
VHA needs the answers to both of those questions to be yes. This domain will support leaders to see where they need to focus efforts to get to the yes. So, if I circle back to EHR and community care, I can't imagine that within this topic, and actually other domains as well, we'll pick up noise, the good and the bad, because these massive undertakings strongly influence care, staffing, a lot of decision-making at the facility level.
And if I could just add, we actually have a whole separate product line that's being built right now to look at community care. It's a massive topic. There are big issues going on. So, it is certainly worthy of its own product line.
Fred Baker
Sure. Another big issue and you mentioned this at the start, if you don't mind, talk about piloting a new mental health psychological review this spring. Can you just give us a little preview of what that will look like?
Dr. Kroviak
Yeah, so they've done a ton of research, the team, and what we're focusing on first is inpatient. So, the provision of inpatient mental health care.
We've never done anything like this to where we're looking at mental health specifically in a cyclical format, and we're hoping to have some really good roll-up data as well. I can't imagine this product line won't expand into the outpatient mental health realm. But, you know, using this as the pilot, I imagine it will bring about a wide variety of cyclical mental health reviews.
Fred Baker
Well, great. Dr. Kroviak, is there anything else you'd like to add about these new reviews?
Dr. Kroviak
So, beyond my enthusiasm and gratitude, the team that is not only finishing up the previous reviews, but brainstorming and really applying so much innovation and creative energy. I really look forward to getting these out and really supporting what is ultimately our goal—to improve health care to veterans.
Fred Baker
Dr. Kroviak, thank you so much for being with us today. The Office of Healthcare Inspections certainly is leaning forward with respect to veteran healthcare oversight. I can't wait to have you back to discuss these products in the future.
Dr. Kroviak
Thank you so much.
Fred Baker
And now I’ll turn is over to our cohost Mary Estacion for our monthly highlights.

Mary
Thanks, Fred. Now some highlights of the work the VA OIG accomplished in February 2023.

VA Inspector General Michael J. Missal testified before a hearing of the House Veterans’ Affairs Committee on February 28. The hearing focused on enhancing accountability at the VA. Mr. Missal spoke about OIG reports that emphasized the need for a strong governance structure and clarity of roles and responsibilities; adequate and qualified staffing; updated information technology systems and business processes; effective quality assurance and monitoring; and stable leadership. Mr. Missal also answered questions regarding OIG findings on military sexual trauma coordinators, processing of Camp Lejeune benefit claims; and the effect of leadership in promoting accountability. As always, you can find the written testimony on our website under the media tab. And we’ve included a link to the committee’s website in the February monthly highlights available under the publications tab if you’d like to watch a recording of the hearing.

Next, some updates on recent investigations.

In the first update, a VA OIG investigation resulted in charges alleging the owner and certifying official of a non-college-degree school conspired to submit fraudulent information to conceal the school’s noncompliance with the rules and regulations of the Post-9/11 GI Bill program. Between September 2012 and August 2018, VA paid more than $17.8 million to the school. The school has since withdrawn from the Post-9/11 GI Bill program. The defendants were indicted in the District of New Hampshire on charges of conspiring to submit a false claim and a false statement.

In the second update, the director of a career school entered into a settlement agreement to resolve allegations of falsely certifying that the school had been operating for more than two years in order to obtain approval to enroll Post-9/11 GI Bill students. The director allegedly provided fictitious documents. The loss to VA is approximately $2.3 million. The director and the school were ordered in the Western District of Texas to pay over $9 million in damages and civil penalties under the False Claims Act. The case was investigated by the VA OIG.

The last investigative update I’ll share involves threats made by a veteran. An incarcerated veteran threatened employees at VA and a nonprofit organization after he received a notification from VA that, per policy, his monetary benefits would be reduced during his incarceration. The veteran was sentenced in the District of Massachusetts to 14 months’ imprisonment and three years’ supervised release after previously pleading guilty to the interstate transmission of a threatening communication. The VA OIG, Federal Bureau of Prisons, and FBI conducted the investigation.

Now for published reports. The OIG published 8 in February. This includes financial efficiency inspections of the VA Palo Alto Health Care System in California and the Northern Arizona VA Health Care System, as well as a CHIP report on the Memphis VA Medical Center in Tennessee.

VA OIG also published the report “Security and Incident Preparedness at VA Medical Facilities.” VA is responsible for securing 171 medical facilities nationwide. Persistent police staffing shortages and concerns about serious incidents led the OIG to conduct a review to provide VA leaders with a snapshot of conditions they observed. OIG teams assessed whether 70 VA facilities had established minimum security plans and taken required actions per VA policy. The OIG identified multiple security vulnerabilities and deficiencies. These included staffing challenges contributing to the lack of a visible and active police presence, and insufficient security personnel resources, such as suitable police operations rooms, operable surveillance cameras with consistent monitoring, and inadequate equipment. Additional measures were also needed for “target hardening,” such as securing doors and restricting access to high-risk areas. Our teams also found that facilities could improve communication with local law enforcement and incident readiness trainings. VA concurred with the OIG’s six recommendations related to police staffing and other measures to improve vulnerabilities in security and incident preparedness.

For more information, you can check out a recent Veteran Oversight Now podcast episode where host Fred Baker spoke with Shawn Steele, whose team worked on this report. This podcast episode can be found on all major podcast providers like Apple and Spotify or on the VA OIG website, under the media tab.

In another report, the OIG reviewed concerns related to the Patient Safety Program at the Tuscaloosa VA Medical Center and the oversight provided. Among the issues: failures to timely finalize approximately 160 patient safety incident reports, required patient safety root cause analyses and risk assessments. The former patient safety manager partially attributed deficiencies to lack of support, supervisory engagement, and resources. Although the facility’s organizational structure permitted multiple pathways for oversight of the Patient Safety Program, there were missed opportunities to identify or mitigate gaps in the program. The OIG concluded a lack of action by facility leaders is partly the cause for these missed opportunities. VA concurred with the OIG’s 11 recommendations related to patient safety event reporting, program oversight, and accountability.

For more information about these and other reports published in February—as well as recent updates to other investigations—go to our website at va.gov/oig and select “reports” under the Publications tab.

That’s it for this episode of Veteran Oversight Now. Listen to past episodes wherever you listen to podcasts. Thanks for tuning in!

This has been an official podcast of the VA Office of Inspector General. Veteran Oversight Now is produced by the Office of Communications and Public Affairs and is available at va.gov/oig. Tune in monthly to hear how the VA OIG serves veterans, their families, and caregivers through meaningful independent oversight. Check out the website for more on the VA OIG oversight mission, read current reports, and keep up to date on the latest criminal investigations. Report potential crimes related to VA; waste or mismanagement; potential violations of laws, rules, or regulations; or risks to patients, employees, or property to the OIG online or call the hotline at 1-800-488-8244. If you are a veteran in crisis or concerned about one, call the Veterans Crisis Line at 1-800- 273-8255, press 1, and speak with a qualified responder now.