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    Government

    Veteran Oversight Now

    Veteran Oversight Now is an official podcast of the Department of Veteran Affairs, Office of Inspector General. Each episode features interviews with key stakeholders, discussions on high-impact reports, and highlights of recent oversight work. Listen regularly for the inside story on how the VA OIG investigates crimes and wrongdoings, audits programs that provide benefits and services to veterans, and inspects medical facilities to ensure our nation’s veterans receive safe and timely health care.

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    Copyright: © 2025 VA OIG

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    Latest Episodes:
    “I don’t want to die.” Veteran Left Alone in VA Emergency Department Dies from Suicide Aug 24, 2023
    Show notes

    In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses deficiencies in the quality of emergency department care for a veteran who died by suicide at the John Cochran Division of the VA St. Louis Healthcare System in Missouri. This edition also includes highlights of the VA OIG’s work from July 2023.

    “Approximately 10 minutes later is when the staff person finds the patient unresponsive in the exam room with a ligature around his neck. A code was called, meaning a code blue so that all emergency staff would present to that room, and they tried to resuscitate the patient, but that was unsuccessful, and he was pronounced dead about 10 to 15 minutes later.”

    – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director

    Related Report

    Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri


    Veteran Suicide at Outpatient Clinic in South Carolina Highlights Tragic Missteps in Patient Care Jul 26, 2023
    Show notes

    In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses missteps in the care of a veteran who eventually committed suicide on the grounds of the Aiken Community Based Outpatient Clinic, part of the Charlie Norwood VA Medical Center in Augusta, Georgia. This edition also includes highlights of the VA OIG’s work from June 2023.


    “In VA you're assigned a primary care provider called your PCP, that, in theory, should be the main provider you see. That's where all of your referrals start for specialty care, and that's how you gain continuity of care. Unfortunately, with this veteran he saw one provider, and then the next appointment saw a different provider, and then the third appointment saw a third provider.”

    – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director

    Related Report:

    • Deficient Care of a Patient Who Died by Suicide and Facility Leaders’ Response at the Charlie Norwood VA Medical Center in Augusta, Georgia

    Oversight, Employee Participation Critical to Patient Safety Programs Says Healthcare Hotline Director Jun 15, 2023
    Show notes

    In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses how she and her team triage healthcare-related hotline inquiries. She shares how concerns over the management of a patient safety program led to an inspection and subsequent report at the Tuscaloosa VA Medical Center in Alabama. This edition also includes highlights of the VA OIG’s work from May 2023.

    “I think the takeaway for all of this is VHA needs to ensure involvement of all staff in the patient safety program at the respective facilities, but also ensure oversight of those safety patient safety programs. The oversight is just as important as participation when trying to ensure that the facility has opportunities to identify system vulnerabilities and then address those concerns with the hopes of preventing future patient safety events from occurring.” Trina Rollins, Director of Hotline Coordination, Office of Healthcare Inspections

    Related Publications:

    • Deficiencies in the Patient Safety Program and Oversight Provided by Facility and VISN Leaders at the Tuscaloosa VA Medical Center in Alabama
    • Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center in Alabama(September 2, 2020)
    • Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center, Alabama(September 27, 2019)

    IG Michael J. Missal Discusses VA OIG's 89th Semiannual Report to Congress May 24, 2023
    Show notes

    IG Michael J. Missal discusses the VA OIG's 89th Semiannual Report to Congress covering the reporting period of October 1, 2022, to March 31, 2023. Plus oversight highlights from the VA OIG's work in March and April of 2023.

    For this six-month period, the VA OIG identified more than $401 million in monetary impact for a return on investment of $4 for every dollar spent on oversight. These figures do not include the inestimable value of the healthcare oversight work completed to advance patient safety and quality care.

    During this six-month period, the Office of Investigations opened 222 cases and closed 217 (most of which were opened in prior periods), with efforts leading to 122 arrests. The OIG hotline received and triaged 15,526 contacts to help identify wrongdoing and address concerns with VA activities. Collectively, the work during this period resulted in 595 administrative sanctions and actions.

    The Office of Audits and Evaluations (OAE) produced 52 work products, including one VA management advisory memorandum that highlighted concerns requiring VA’s prompt attention, 19 oversight reports, and 32 preaward and postaward contract reviews to help VA obtain fair and reasonable pricing on products and services. OAE reports for the six-month period resulted in 128 recommendations.

    The Office of Special Reviews issued two publications, including an administrative investigation that focused on VHA employing four people who had been previously excluded from holding a paid position in a federal healthcare program.

    The Office of Healthcare Inspections (OHI) focused on leadership and organizational risks, suicide risk reduction, and care coordination. OHI published 14 healthcare inspection reports; two national healthcare reviews; 11 Comprehensive Healthcare Inspection Program (CHIP) reports, including four CHIP summary reports; two Vet Center Inspection Program reports; and two Care in the Community reports.

    Featured Publications:
    Stronger Controls Help Ensure People Barred from Paid Federal Healthcare Jobs Do Not Work for VHA

    Veterans Are Still Being Required to Attend Unwarranted Medical Reexaminations for Disability Benefits

    Deficiencies in Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning for Patients with Suicidal Behaviors by Firearms

    Opioid Safety at the VA Northern California Health Care System in Mather


    Proactive Oversight: Senior Leader Shares How the VA OIG is Changing Some Healthcare Inspections Mar 23, 2023
    Show notes

    In this episode, host Fred Baker talks with Dr. Julie Kroviak, the principal deputy assistant inspector general of the VA OIG’s Office of Healthcare Inspections, about changes to how cyclical healthcare reviews are conducted. Dr. Kroviak explains how her teams are reworking the Comprehensive Healthcare Inspection Program cyclical reports to provide more information on the veteran communities being served by VA medical facilities. Additionally, she shares how, for the first time, the VA OIG will start reviewing VA mental health programs cyclically.

    “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 [factors] 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.” – Dr. Julie Kroviak


    VA OIG Teams Tackle Security Posture Problems at VA Medical Facilities Nationwide Feb 22, 2023
    Show notes

    In this episode of Veteran Oversight Now, host Fred Baker talks with Shawn Steele, the director of the VA OIG’s Office of Audits and Evaluations Healthcare Infrastructure Division. Taking a very unique approach, 150 OIG staff recently mobilized to evaluate the security posture of 70 VA medical facilities over three days. Persistent police staffing shortages and growing concerns about incidents that put VA staff, patients, and visitors at risk led the OIG to conduct the review, Security and Incident Preparedness at VA Medical Facilities. OIG teams assessed whether each VA medical facility visited had established a minimum-security posture and had taken required actions according to VA policy. The OIG identified multiple security vulnerabilities and deficiencies, most notably staffing shortages that contributed to the lack of a visible and active police presence.

    “VA medical facilities are meant to be welcoming. They’re meant to be easy to access and as a result have many entrances. On top of that, there are 171 geographically diverse medical facilities in the VA network, and each of them come with their own unique challenges. It’s important to understand that there is not one [security] template that can be applied. There are 171 templates that need to be applied.”
    – Shawn Steele
    Related Report:

    Security and Incident Preparedness at VA Medical Facilities


    VA OIG Psychiatrist Discusses VHA's Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning Jan 19, 2023
    Show notes

    In this episode of Veteran Oversight Now, host Fred Baker chats with Dr. Beth Winter, a psychiatrist with the VA OIG’s Office of Healthcare Inspections. They discuss her path from wanting to provide care for exotic animals to choosing to be “a people doctor instead of an animal doctor.” Dr. Winter’s distinguished career eventually led the granddaughter and daughter of veterans to the VA OIG helping provide oversight of VHA’s health care system. In this podcast, Dr. Winter discusses her work related to the prevention of veteran suicide by lethal means in the recently released report Deficiencies in Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning for Patients with Suicidal Behaviors by Firearms. She explains that the time between a veteran deciding to act and actually attempting suicide can be just five or 10 minutes and relatively simple interventions during that period can be critical in preventing suicide. This month’s episode concludes with a summary of the VA OIG’s oversight highlights for December 2022.

    “That window is really between the decision to act and the action itself and … we also know that if there was some barrier to accessing a person’s initial method for suicide—for example a gun lock, or a gun being placed in a safe, or a gun being separated from ammunition within the house—that gives people time to either reconsider their action, or they might make the attempt with a method that’s significantly less lethal. So, if we can increase that window between the decision to act and the action itself, we significantly increase the possibility of that person’s survival.” – Dr. Beth Winter

    Related Report:

    Deficiencies in Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning for Patients with Suicidal Behaviors by Firearms


    Inspector General Interview: 88th Semiannual Report to Congress Nov 29, 2022
    Show notes

    The Semiannual Report to Congress summarizes the VA Office of Inspector General’s (OIG) oversight efforts from April 1 through September 30, 2022. For this six-month period, the VA OIG identified more than $1.4 billion in monetary impact for a return on investment of $16 for every dollar spent on oversight—which brings the fiscal year 2022 totals to nearly $4.6 billion in monetary impact for a return on investment of $24 for every dollar spent on oversight. These figures do not include the inestimable value of the healthcare oversight work completed to advance patient safety and quality care.

    During this six-month period, the Office of Investigations opened 178 cases and closed 213 (most of which were opened in prior periods), with efforts leading to 135 arrests. The OIG hotline received and triaged 18,396 contacts to help identify wrongdoing and address concerns with VA activities. Collectively, the work during this period resulted in 599 administrative sanctions and actions.

    The Office of Audits and Evaluations (OAE) produced 44 publications, including five VA management advisory memorandums that highlighted concerns requiring VA’s prompt attention. Contracting review teams also conducted 47 preaward and postaward contract reviews to help VA obtain fair and reasonable pricing on products and services. OAE reports for the six-month period resulted in 198 recommendations.

    The Office of Special Reviews (OSR) issued five publications, including three reports in response to allegations of senior VA officials’ misconduct, which reflect the VA OIG’s commitment to holding VA employees accountable for wrongdoing and promoting the highest standards of professional and ethical conduct. OSR also issued two joint publications: a VA management advisory memorandum with OAE regarding concerns with the calculation of patient wait time data, and a report with the Department of Defense (DoD) OIG, focusing on efforts by DoD and VA to achieve electronic health record system interoperability.

    The Office of Healthcare Inspections (OHI) maintained a strong focus on leadership and organizational risks, suicide risk reduction, quality of care, and patient safety. OHI published 19 healthcare inspection reports; 17 Comprehensive Healthcare Inspection Program (CHIP) reports, including three CHIP summary reports; four national healthcare reviews; and its first Care in the Community report that examined key clinical and administrative processes associated with providing quality VA and community care.


    VA OIG Senior Investigator Highlights Noble Mission of Protecting Veterans Nov 01, 2022
    Show notes

    Mentioned Investigations:

    Former VA Hospital Nursing Assistant Sentenced to Seven Consecutive Life Sentences for Murdering Seven Veterans and Assault with Intent to Commit Murder of an Eighth

    Fayetteville Doctor Sentenced To 20 Years In Federal Prison For Mail Fraud And Involuntary Manslaughter

    Retail Ready Owner to Forfeit $72M for VA Tuition Fraud


    OIG Healthcare Leaders Talk VHA Staffing Shortages, Stress on the Workforce Sep 20, 2022
    Show notes

    Related Reports:

    OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages Fiscal Year 2022
    Pursuant to the VA Choice and Quality Employment Act of 2017 (VCQEA), the OIG conducted a review to identify clinical and non-clinical occupations experiencing staffing shortages within Veterans Health Administration (VHA). This is the ninth iteration of the staffing report, and the fifth evaluating facility-level data. The OIG evaluated staffing shortages by surveying VHA facilities, and compared this information to the previous four years.

    The OIG found that all 139 VHA facilities reported at least one severe occupational staffing shortage. The total number of reported severe shortages was 2,622. Twenty-two occupations were identified as a severe occupational staffing shortage by at least one in five facilities. Every year since 2014, the Medical Officer and Nurse occupations were reported as severe shortages. Practical Nurse was the most frequently identified clinical severe occupational staffing shortage in FY 2022, with 62 percent of facilities reporting this occupation. Custodial Worker was the most frequently reported non-clinical severe occupational shortage in FY 2022, with 69 percent of facilities reported the occupation. Medical Support Assistance was the most frequently reported Hybrid Title 38 severe occupational shortage.

    In FY 2022, VHA reported twenty-two percent more severe occupational staffing shortages as compared to FY 2021. FY 2022 is the first year since implementation of VCQEA reporting requirements in which the OIG did not observe a yearly decrease in the overall number of severe occupational staffing shortages; it was also the first time that facilities identified more than 90 occupations as severe shortages. The OIG again determined the ongoing need for Custodial Worker and Medical Support Assistance, noting an increase in the number of facilities identifying these occupations as severe shortages. The OIG emphasizes the importance of VHA’s continued assessment of severe occupational staffing shortages given the increases from FY 2021 to FY 2022.

    The Veterans Health Administration Needs to Do More to Promote Emotional Well-Being Supports Amid the COVID-19 Pandemic
    The Veterans Health Administration (VHA) Office of Emergency Management issued the initial COVID-19 Response Plan on March 23, 2020, and then an updated version on August 7, 2020. The National Center for Organization Development created a COVID-19 rapid response consultation process for VHA leaders in a supervisory role. The Organizational Health Council developed a team that coordinated with multiple VHA program offices to create a COVID-19 Employee Support Toolkit and other resources. Additionally, several program offices independently created and disseminated employee well-being resources specific to the COVID-19 pandemic, including National Center for Organization Development, Patient Centered Care & Cultural Transformation, Chaplain Service, and the Office of Mental Health and Suicide Prevention.

    The VA Office of Inspector General (OIG) identified a generally diminishing awareness of employee emotional well-being supports in relation to organizational hierarchy, low utilization of support resources by leadership and frontline employees, as well as employee perception of inadequate support and responsiveness from leadership.

    The OIG conducted a review to assess how the VHA addressed the emotional well-being of employees during the COVID-19 pandemic. The OIG also conducted an overview of VHA programs, including what specialized programs were developed and deployed in response to the unique psychological challenges created by the COVID-19 pandemic for VHA’s staff. The OIG interviewed VA and VHA leaders in multiple offices. The OIG developed and deployed a survey about VHA guidance regarding employees’ emotional well-being during the pandemic, available resources, monitoring of available support programs, and employee engagement with available support programs.

    The OIG made one recommendation to the Under Secretary for Health related to increasing leadership and staff awareness of COVID-19 emotional well-being resources for VHA employees and awareness of resources about potential risks and signs of burnout.


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