Report Summary

This administrative investigation addressed concerns of possible misconduct by two leaders responsible for overseeing medical facility staff training on implementing VA’s new multibillion-dollar patient electronic health record system. The investigation stemmed from a prior OIG review at the initial operating site (the Mann-Grandstaff VA Medical Center in Spokane, Washington), during which OIG healthcare inspectors experienced significant challenges in receiving timely, complete, and accurate information from the then VA Office of Electronic Health Record Modernization’s (OEHRM’s) Change Management group.

The investigation revealed that while the Change Management leaders did not intentionally seek to mislead the OIG, their lack of diligence resulted in delays and misinformation being submitted that impeded oversight efforts. Failures included (1) submitting a training evaluation plan without disclosing to the OIG that it was in its “infancy” and had not been fully implemented or even approved; (2) delaying production of requested proficiency check datasets that should have been available under the submitted evaluation plan; (3) instead providing three summary statistics with errors that doubled the training proficiency test pass rate from initial findings of 44 to 89 percent, without the requested methodology; (4) overlooking red flags indicating that all failing scores had in fact been removed from reported rates (with the total number of proficiency tests dropping by more than 3,000 in submitted recalculations); and (5) failing to disclose concerns regarding data reliability and that data were excluded.

VA concurred with the OIG’s two recommendations for providing guidance to staff in the since-reorganized Electronic Health Record Modernization and Integration Office on providing timely, complete, and accurate responses to OIG staff and ensuring direct staff-level communications with OIG personnel are not impeded. VA also agreed to consider whether administrative action is appropriate given the conduct and performance of the two Change Management leaders.