Recommendations
2056
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-00101-137 | Comprehensive Healthcare Inspection of the VA Bedford Healthcare System in Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures leaders conduct institutional disclosures for applicable sentinel events.
Closure Date:
2 The Director ensures staff complete a root cause analysis for all events assigned an actual or potential safety assessment code score of 3.
Closure Date:
3 The Associate Director ensures staff keep patient areas clean and free from undue wear.
Closure Date:
4 The Director ensures staff check over-the-door alarms on the mental health inpatient unit according to the manufacturer’s guidelines.
Closure Date:
5 The Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in ambulatory care settings.
Closure Date:
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| 22-04014-130 | Comprehensive Healthcare Inspection of the Bay Pines VA Healthcare System in Florida | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures leaders conduct institutional disclosures for applicable sentinel events.
Closure Date:
2 The Director ensures staff complete a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
Closure Date:
3 The Associate Director ensures Environmental Management Service staff keep areas used by patients clean and orderly.
Closure Date:
4 The Associate Director ensures staff keep furnishings and walls in good repair.
Closure Date:
5 The Associate Director ensures staff use solid bottom shelves in storage areas.
Closure Date:
6 The Associate Director ensures staff inspect, test, and maintain medical equipment.
Closure Date:
7 The Associate Director ensures staff document VA police response times for panic alarm testing in the mental health inpatient unit.
Closure Date:
8 The Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to quality management staff.
Closure Date:
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| 23-00013-128 | Comprehensive Healthcare Inspection of the VA Salt Lake City Health Care System in Utah | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs report Focused Professional Practice Evaluation results to an executive committee of the medical staff for consideration in privileging recommendations.
Closure Date:
2 The Director ensures staff conduct environment of care inspections in patient care areas as required.
Closure Date:
3 The Director ensures staff test panic alarms in the Inpatient Psychiatry Unit at least quarterly and record testing in a log, including police response times.
Closure Date:
4 The Director ensures staff test over-the-door alarms in the Inpatient Psychiatry Unit per the manufacturer’s recommendations.
Closure Date:
5 The Director ensures staff keep interior spaces in the Inpatient Psychiatry Unit safe and suitable for care.
6 The Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.
Closure Date:
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| 22-02398-131 | Veterans Health Administration’s Failure to Properly Identify and Exclude Ineligible Providers from the VA Community Care Program | National Healthcare Review | ||
1 The Under Secretary for Health reviews the criteria and processes used to identify and exclude healthcare providers removed from VA employment for violation of policy related to safe and appropriate care of veterans, and takes action as warranted.
2 The Under Secretary for Health reviews previous removals of healthcare providers from VA employment as required by VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 § 108 to determine whether the reason(s) for those removals were for violation of policy related to the safe and appropriate care of veterans, and takes action as warranted.
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| 23-00876-74 | Improved Oversight Needed to Evaluate Network Adequacy and Contractor Performance | Audit | ||
1 Holds future third-party administrators accountable for operational readiness and provider network adequacy at each facility by the time the contracts are implemented.
Closure Date:
2 Develops a process to make sure the third-party administrators regularly update their Community Care Network provider lists to reflect accurate provider contact information and annotate providers who are not currently accepting VA patients.
Closure Date:
3 Develops a mechanism for facilities to effectively report, track, and monitor challenges with access to specialty care services; trains all relevant staff on how to use the mechanism; make sure facilities use the mechanism routinely; and then helps facilities resolve access challenges.
Closure Date:
4 Develops and communicates to facilities a standard process to request and document their needs for additional providers.
Closure Date:
5 Evaluates the effectiveness of the third-party administrators’ quarterly and monthly reports for assessing network adequacy and then, if needed, modifies the language in its current contracts and makes changes to the applicable contract language for future Community Care Network contracts.
Closure Date:
6 Develops its own network adequacy performance reports for each facility and communicates the results to the facilities monthly.
Closure Date:
7 Conducts Advanced Medical Cost Management Solution training for community care staff at each facility on evaluating network adequacy through the tool.
Closure Date:
8 Routinely evaluates the third-party administrator’s network adequacy performance reports to ensure the reports are sufficiently reliable and comply with contract requirements, and then holds third-party administrators accountable for resolving identified issues.
Closure Date:
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| 23-00016-132 | Comprehensive Healthcare Inspection of the Syracuse VA Medical Center in New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures staff record the Peer Review Committee’s formal discussions related to changes in peer review level assignments in the meeting minutes.
Closure Date:
2 The Chief of Staff ensures the Medical Staff Executive Committee reviews data provided by the Peer Review Committee to determine the need for further action.
Closure Date:
3 The Chief of Staff ensures service chiefs complete Ongoing Professional Practice Evaluations prior to reprivileging to ensure continuous delivery of quality care.
Closure Date:
4 The Chief of Staff ensures service chiefs use specialty-specific criteria in the professional practice evaluations of licensed independent practitioners.
Closure Date:
5 The Associate Director ensures the Comprehensive Environment of Care Rounds Coordinator or designee schedules environment of care inspections and staff complete and document them at the required frequency.
Closure Date:
6 The Associate Director ensures staff keep patient care areas safe and clean.
Closure Date:
7 The Medical Center Director ensures staff document police response times to panic alarm testing in the mental health inpatient unit.
Closure Date:
8 The Medical Center Director ensures staff test over-the-door alarms based on the manufacturer’s recommendations for mental health inpatient unit sleeping rooms.
Closure Date:
9 The Medical Center Director ensures staff check all mental health inpatient unit ceiling tiles semiannually.
Closure Date:
10 The Veterans Integrated Service Network Director ensures the Medical Center Director has sufficient biomedical staff and confirms they inspect and test all medical equipment for scheduled maintenance.
Closure Date:
11 The Veterans Integrated Service Network Director ensures compliance with VHA Directive 1860, Biomedical Engineering Performance Monitoring and Improvement, for oversight structure of the medical center’s biomedical program.
Closure Date:
12 The Medical Center Director ensures designated staff complete the Comprehensive Suicide Risk Evaluation on the same calendar day as a positive suicide risk screen, when clinically appropriate, for all ambulatory care patients.
Closure Date:
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| 22-03013-129 | Deficiencies in Attention Deficit Hyperactivity Disorder Diagnostic Assessment, Evaluation of Stimulant Medication Risks, and Policy Guidance | National Healthcare Review | ||
1 The Under Secretary for Health ensures Veterans Health Administration prescribers establish a diagnosis based on a complete and documented assessment prior to initiation of a stimulant to treat attention deficit hyperactivity disorder.
Closure Date:
2 The Under Secretary for Health ensures Veterans Health Administration prescribers assess risks and contraindications associated with stimulant prescribing.
3 The Under Secretary for Health evaluates the prescription drug monitoring program query adherence goal for initial stimulant prescribing and takes action as warranted.
Closure Date:
4 The Under Secretary for Health evaluates the adequacy of the referral processes related to complex mental health disorders, such as attention deficit hyperactivity disorder, and takes action as warranted.
Closure Date:
5 The Under Secretary for Health considers establishing policy and clinical practice guidance related to attention deficit hyperactivity disorder diagnostic assessment and treatment with a stimulant and takes action as warranted.
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| 22-04112-125 | Comprehensive Healthcare Inspection of the VA Northern Indiana Health Care System in Marion | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs define the time frames for Focused Professional Practice Evaluations.
Closure Date:
2 The Chief of Staff ensures service chiefs recommend reprivileging based, in part, on Ongoing Professional Practice Evaluation activities
Closure Date:
3 The Director ensures staff remove corrugated containers from patient care areas.
Closure Date:
4 The Director ensures staff keep storerooms clean and free of visible dust and soiling.
Closure Date:
5 The Director ensures Environmental Management Services staff keep patient care areas clean.
Closure Date:
6 The Associate Director for Patient Care Services ensures staff remove expired commercial products from patient care areas.
Closure Date:
7 The Director ensures staff store clean and dirty equipment separately.
Closure Date:
8 The Director ensures staff maintain walls to allow for thorough cleaning.
Closure Date:
9 The Associate Director ensures staff test over-the-door alarms in the Inpatient Mental Health unit per the manufacturer’s recommendations.
Closure Date:
10 The Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.
Closure Date:
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| 23-00109-121 | Comprehensive Healthcare Inspection of the VA Maine Healthcare System in Augusta | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures leaders identify and evaluate sentinel events and conduct and document institutional disclosures when criteria are met.
Closure Date:
2 The Medical Center Director ensures staff complete a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
Closure Date:
3 The Chief of Staff ensures service chiefs recommend reprivileging for licensed independent practitioners based, in part, on Ongoing Professional Practice Evaluation data.
Closure Date:
4 The Chief of Staff ensures staff report licensed independent practitioners’ Focused Professional Practice Evaluation results to the Clinical Executive Board.
Closure Date:
5 The Veterans Integrated Service Network Chief Medical Officer provides effective oversight of credentialing and privileging processes at the healthcare system.
Closure Date:
6 The Medical Center Director ensures the comprehensive environment of care coordinator schedules environment of care inspections at the required frequency and verifies staff complete and document them.
Closure Date:
7 The Medical Center Director ensures staff document police response times to panic alarm testing in the Inpatient Mental Health Unit.
Closure Date:
8 The Medical Center Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on Inpatient Mental Health Unit sleeping room doors.
Closure Date:
9 The Medical Center Director ensures staff maintain a safe environment in the Inpatient Mental Health Unit.
Closure Date:
10 The Medical Center Director ensures staff post hazard warning signs on all access doors where potentially infectious materials are located.
Closure Date:
11 The Medical Center Director ensures staff keep patient care areas safe and clean.
12 The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.
Closure Date:
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| 23-00111-119 | Comprehensive Healthcare Inspection of the Oscar G. Johnson VA Medical Center in Iron Mountain, Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures staff identify sentinel events and take appropriate action when home oxygen fires occur.
Closure Date:
2 The Veterans Integrated Service Network Director ensures network staff track and monitor home oxygen vendor completion of root cause analyses when sentinel events occur.
Closure Date:
3 The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.
Closure Date:
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14921