Recommendations
2159
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 25-01015-138 | Audit of Consult Timeliness for VA and Community Care | Audit | ||
1 Conduct a strategic business evaluation of the process used by VA medical facilities’ scheduling departments to determine whether alternatives could improve consult processing, scheduling efficiency, and timeliness.
2 Establish procedures to track and provide oversight of consults that schedulers have not acted on to schedule and prioritize processing of those consults when identified.
Closure Date:
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| 25-01014-139 | Audit of Veterans’ Community Care Eligibility Determinations | Audit | ||
1 Establish and use agreements with other VA medical facilities to help identify and schedule direct care when local services are not available.
2 Assess options to improve the scheduling process and system to provide schedulers with access to community care provider appointment availability when discussing care options with wait time–eligible veterans.
3 Review services in the Consult Toolbox to make sure it accurately reflects available services and avoids inaccurate eligibility determinations.
4 Reinforce requirements for schedulers to review scheduling systems to identify the next available date for appointments and input that information in the Consult Toolbox.
5 Implement a process to verify that schedulers check all community care eligibility criteria for all veterans.
6 Emphasize to schedulers at least annually the proper methods (including the use of opt-out codes) to document when veterans opt out of community care.
Total Monetary Impact of All Recommendations
Open: $1,744,845,232
Closed: $0
Total: $1,744,845,232
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| 25-02152-136 | Review of Ear, Nose, and Throat Surgery-Related Sterile Processing Services Concerns at the Michael E. DeBakey VA Medical Center in Houston, Texas | Hotline Healthcare Inspection | ||
1 The Michael E. DeBakey VA Medical Center Director uses available resources to help recruit and hire an assistant chief of Sterile Processing Services.
2 The Michael E. DeBakey VA Medical Center Director, in conjunction with the chief of Sterile Processing Services, reviews reusable medical device inventory management and oversight processes to ensure compliance with Veterans Health Administration requirements, identifies deficiencies, and takes action as warranted.
3 The Michael E. DeBakey VA Medical Center Director reviews processes to track issue briefs related to surgery cancellations resulting from reusable medical device issues from initiation to closure, identifies deficiencies, and takes action as necessary.
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| 25-00240-125 | Healthcare Facility Inspection of the VA Illiana Healthcare System in Danville, Illinois | Healthcare Facility Inspection | ||
1 Facility leaders ensure staff place signs on or near each building to help veterans easily navigate where services are located.
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| 25-01013-135 | Review of Clinical Care and Behavior Concerns about Two Surgeons at the Martinsburg VA Medical Center in West Virginia | Hotline Healthcare Inspection | ||
1 The Martinsburg VA Medical Center Director conducts a comprehensive review of the peer review process from identification to completion to ensure adherence with Veterans Health Administration Directive 1190(1), Peer Review for Quality Management, amended July 19, 2024, and takes action as warranted.
2 The Martinsburg VA Medical Center Director ensures the chief of surgery assesses Surgeon B’s alleged disruptive behavior and takes action if needed, in accordance with VA Handbook 5021, Employee-Management Relations, and Martinsburg VA Medical Center bylaws.
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| 26-00182-140 | Review of Generative Artificial Intelligence Chat Tools for Clinical Use | National Healthcare Review | ||
1 The Under Secretary for Health reviews the Veterans Health Administration’s current use of generative AI chat tools, defines permissible clinical uses for general-purpose AI chat tools, oversight responsibilities, and risk mitigation, and outlines a plan for implementation.
2 The Under Secretary for Health evaluates whether safeguards applied to other high-impact AI tools, such as Ambient AI Scribe, should be adapted for generative AI chat tools used for clinical care and documentation.
3 The Under Secretary for Health oversees integration of AI-related risk monitoring into existing patient safety programs and ensures staff are trained to identify and report AI-related safety events.
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| 25-00523-82 | Audit of VA’s Police Staffing Decision Tool | Audit | ||
1 Identify all relevant stakeholders and formally define roles and responsibilities for the police staffing decision tool or similar model.
2 Coordinate with all relevant stakeholders to address vulnerabilities with the police staffing decision tool or a similar model.
3 Ensure the Manpower Management Service’s standard operating procedures are followed to document formal completion of the police staffing decision tool or a similar model.
4 Assign accountability for disseminating the finalized police staffing decision tool or a similar model and ensuring its use.
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| 25-00734-134 | Review of Care Provided to a Patient Who Died by Suicide and the Subsequent Root Cause Analysis at the Robley Rex VA Medical Center in Louisville, Kentucky | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director conducts a comprehensive review of the care provided to the patient prior to the event, and takes action as indicated.
2 The Robley Rex VA Medical Center Director ensures that the facility has a mechanism in place for how Veterans Health Administration healthcare professionals will provide content of suicide prevention safety plans when completing suicide prevention safety plans with patients over the phone.
3 The Robley Rex VA Medical Center Director reviews facility Primary Care-Mental Health Integration guidance documents and ensures consistency and alignment with Veterans Health Administration requirements.
4 The Robley Rex VA Medical Center Director reconsiders the practice of reauthoring notes in the Computerized Patient Record System by behavioral health technicians in the Primary Care-Mental Health Integration call center, identifies other facility areas that use the reauthoring process, and takes action as indicated.
5 The Under Secretary for Health evaluates ways to mitigate the implications resulting from users’ ability to change authors in an unsigned note in the Computerized Patient Record System to ensure that such practice is limited to those in roles with a need to have that function, and takes action as indicated.
6 The Robley Rex VA Medical Center Director ensures that root cause analyses are completed in accordance with Veterans Health Administration policy, including root cause analysis process steps, timeliness, and team roles.
7 The Robley Rex VA Medical Center Director ensures that patient safety managers receive oversight, training, and support as required by the Veterans Health Administration.
8 The Robley Rex VA Medical Center Director ensures that the chief of quality understands the seriousness and implications of altering documentation without support, and that leaders, whose actions contributed to the deficiencies outlined in this report, receive administrative action, as appropriate.
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| 25-04138-129 | Review of the Peer Review Process at the VA Caribbean Healthcare System in San Juan, Puerto Rico | Hotline Healthcare Inspection | ||
1 The VA Caribbean Healthcare System Director ensures that facility leaders make decisions regarding the need for institutional disclosures independent of the peer review process in alignment with VHA Directive 1190 (1), Peer Review for Quality Management.
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| 25-02766-130 | Review of Inpatient Mental Health Unit Processes at the West Palm Beach VA Healthcare System in Florida | Hotline Healthcare Inspection | ||
1 The West Palm Beach VA Healthcare System Director ensures 3C leaders are aware of and comply with Mental Health Environment of Care Checklist requirements on the inpatient mental health unit.
2 The West Palm Beach VA Healthcare System Director reviews the inpatient mental health patient safety observation practices to ensure compliance with VHA SOP 1160.06.1, “Standard Operating Procedure for Maintaining Safety and Security on Inpatient Mental Health Units Under VHA Directive 1160.06,” and Facility Medical Center Policy 118-01, Enhanced Observation Level requirements.
3 The West Palm Beach VA Healthcare System Director ensures staff performing patient safety observation on 3C receive recurring training on conducting observation practices, including face-to-face visualization, in alignment with VHA SOP 1160.06.1, “Standard Operating Procedure for Maintaining Safety and Security on Inpatient Mental Health Units Under VHA Directive 1160.06,” requirements.
4 The West Palm Beach VA Healthcare System Director develops and implements an oversight process for ongoing monitoring of inpatient mental health patient safety observation practices and documentation to ensure compliance with VHA SOP 1160.06.1, “Standard Operating Procedure for Maintaining Safety and Security on Inpatient Mental Health Units Under VHA Directive 1160.06” requirements.
5 The West Palm Beach VA Healthcare System Director develops a plan to reassess the effectiveness of the oversight process.
6 The West Palm Beach VA Healthcare System Director ensures that when 3C leaders identify incongruencies between patient safety observation practice and documentation, 3C leaders conduct a review of the incident and take corrective action, as warranted.
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15477