Recommendations
2055
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 11-00324-20 | Audit of VA’s Office of Information Technology Strategic Human Capital Management | Audit | ||
1 We recommended that the Assistant Secretary for Information Technology establish a strategic human capital plan development process that includes Office of Information Technology's senior management, managers, and employees along with appropriate stakeholders from across VA and its administrations.
Closure Date:
2 We recommended that the Assistant Secretary for Information Technology develop and implement a strategic human capital plan that includes roles and responsibilities; human capital goals, objectives, and strategies; performance measures; and milestones as outlined in the Human Capital Assessment and Accountability Framework.
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3 We recommended that the Assistant Secretary for Information Technology ensure the Office of Information Technology's strategic human capital plan is aligned with VA's missions, goals, and objectives; and integrated into the Information Technology and VA Strategic Plans.
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4 We recommended that the Assistant Secretary for Information Technology ensure the Office of Information Technology has an adequate number of leadership and staff positions assigned to administer its strategic human capital program.
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5 We recommended that the Assistant Secretary for Information Technology develop a leadership succession plan, including key actions and associated milestones for its implementation.
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6 We recommended that the Assistant Secretary for Information Technology ensure that all information technology leadership and employee competency assessments and gap analyses are completed.
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7 We recommended that the Assistant Secretary for Information Technology develop leadership and workforce development and hiring strategies for closing identified competency gaps.
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8 We recommended that the Assistant Secretary for Information Technology maintain a current listing of contracts used by each OIT organizational element and the functions performed to identify areas where OIT uses contractors to address competency gaps.
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9 We recommended that the Assistant Secretary for Information Technology institute metrics and a process to measure the effectiveness of its strategies for evaluating and improving human capital management.
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| 11-03462-17 | Healthcare Inspection - Respiratory Care and Other Clinical Concerns, VA Northern Indiana Health Care System, Fort Wayne, IN | Hotline Healthcare Inspection | ||
1 We recommended that the facility Acting Director ensures that facility respiratory care policies are updated, including specific guidance and expectations for ordering oxygen therapy.
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2 We recommended that the facility Acting Director ensures that peer review processes comply with VHA policy.
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3 We recommended that the facility Acting Director implements procedures to complete an assessment of ABG usage.
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| 12-03594-10 | Healthcare Inspection – Delays for Outpatient Specialty Procedures, VA North Texas Health Care System, Dallas, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that patients receive timely vascular and cardiology care and that compliance is monitored.
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2 We recommended that the Facility Director ensure that providers document review of consults in the EHR and link results to consult requests and that compliance is monitored.
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3 We recommended that the Facility Director ensure that staff comply with VHA policy for scheduling outpatient appointments and that compliance is monitored.
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| 11-01823-294 | Audit of VA’s Systems Interconnections with Research and University Affiliates | Audit | ||
1 We recommend the Assistant Secretary for Information and Technology establish or update all Memoranda of Understanding and Interconnection Security Agreements needed to accurately reflect operational environments and require that research partners implement information security controls commensurate with VA's information security standards.
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2 We recommend the Assistant Secretary for Information and Technology support the Under Secretary for Health by providing the information technology infrastructure needed to implement a centralized data governance and storage model to securely manage research information over the data life cycle.
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3 We recommend the Assistant Secretary for Information and Technology direct Information Security Officers to partner with the Veterans Health Administration's Institutional Review Boards, research personnel, and research partners to routinely conduct joint oversight and monitoring of research labs to ensure security of sensitive veterans' data, compliance of data collections with research protocols, and fulfillment of the Department's information security requirements.
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4 We recommend the Under Secretary for Health develop and implement a centralized data governance and storage model that ensures accurate inventory of all research data collected, data collection compliance with research protocols, and secure management of research information over the data life cycle.
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5 We recommend the Under Secretary for Health require the Office of Research and Development to partner with Information Security Officers to routinely conduct joint oversight and monitoring of research labs to ensure security of sensitive veterans' data, compliance of data collections with research protocols, and fulfillment of the Department's information security requirements.
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| 12-02601-07 | Combined Assessment Program Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, Oregon | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that patients are notified of positive CRC screening test results within the required timeframe and that clinicians document notification.
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2 We recommended that processes be strengthened to ensure that responsible clinicians either develop follow-up plans or document that no follow-up is indicated within the required timeframe.
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3 We recommended that the facility implement an effective fee basis referral process to ensure patients receive diagnostic testing within the required timeframe and that compliance with the new process be monitored.
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4 We recommended that processes be strengthened to ensure that patients are notified of diagnostic test results within the required timeframe and that clinicians document notification.
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5 We recommended that processes be strengthened to ensure that patients are notified of biopsy results within the required timeframe and that clinicians document notification.
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6 We recommended that processes be strengthened to ensure that patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
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7 We recommended that the facility establish an EHR Committee that meets VHA requirements and clearly define the responsibilities of the committee.
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| 12-02189-14 | Combined Assessment Program Review of the VA Long Beach Healthcare System, Long Beach, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that compliance be monitored.
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2 We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results and document the actions taken.
Closure Date:
3 We recommended that processes be strengthened to ensure that patients are notified of positive CRC screening test results within the required timeframe and that clinicians document notification.
Closure Date:
4 We recommended that processes be strengthened to ensure that responsible clinicians either develop follow-up plans or document that no follow-up is indicated within the required timeframe.
Closure Date:
5 We recommended that processes be strengthened to ensure that patients with positive CRC screening test results receive diagnostic testing within the required timeframe.
Closure Date:
6 We recommended that processes be strengthened to ensure that patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
Closure Date:
7 We recommended that processes be strengthened to ensure that outpatients who need interdisciplinary care have treatment plans developed.
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8 We recommended that processes be strengthened to ensure that all discharged MH patients who are not on the high risk for suicide list receive follow-up within the specified timeframes and that compliance be monitored.
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9 We recommended that all discharged MH patients who are on the high risk for suicide list receive follow-up at the required intervals and that compliance be monitored.
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10 We recommended that processes be strengthened to ensure that discharge instructions address diet and the initial follow-up appointment.
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11 We recommended that processes be strengthened to ensure that safety inspections are conducted on all ceiling lifts in the SCI Center and documented.
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12 We recommended that processes be strengthened to ensure that all required participants or their designees consistently attend EOC rounds.
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13 We recommended that processes be implemented to report results of tracking and trending of inter-facility transfers to the Organizational Excellence Board and to incorporate education on inter-facility transfers into new resident orientation.
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14 We recommended that processes be strengthened to ensure that EOC deficiencies are corrected within the required timeframe and that action plans are submitted for deficiencies not corrected within the required timeframe.
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15 We recommended that facility managers conduct a comprehensive EOC inspection of the facility and take appropriate actions to correct identified general cleanliness and maintenance issues.
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| 12-02098-11 | Healthcare Inspection – Reusable Medical Equipment Issues, VA Northern California Health Care System, Sacramento, CA | Hotline Healthcare Inspection | ||
1 The VISN Director requires the System Director to review the findings in this report and take steps to correct all identified deficiencies.
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| 12-01487-08 | Healthcare Inspection - Delay in Treatment, Louis Stokes VA Medical Center, Cleveland, OH | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director strengthen local policies by including all VHA required elements regarding procedures for contacting patients to schedule appointments.
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2 We recommended that the Facility Director strengthen processes for clinic scheduling and consult tracking and monitor timeliness of outpatient scheduling processes for adherence with Veterans Health Administration timeliness requirements.
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| 12-01903-04 | Review of VA's Alleged Incomplete Installation of Encryption Software Licenses | Audit | ||
1 We recommended the Assistant Secretary for Information Technology complete the software encryption project assessment to determine whether to continue or terminate the project.
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2 We recommended the Assistant Secretary for Information Technology, if it is determined to continue the project, develop a plan that includes sufficient human resources and monitoring to install and activate all of the purchased encryption software licenses.
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| 12-02599-03 | Combined Assessment Program Review of the Minneapolis VA Health Care System, Minneapolis, Minnesota | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that compliance be monitored.
Closure Date:
2 We recommended that processes be strengthened to ensure that all patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
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3 We recommended that minimum polytrauma staffing levels be maintained.
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4 We recommended that the facility monitor compliance with polytrauma training requirements.
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5 We recommended that processes be strengthened to ensure that Case Managers consistently communicate with the inpatient and/or their family at the required intervals.
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6 We recommended that processes be strengthened to ensure that polytrauma patient care areas are clean and well maintained.
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7 We recommended that processes be strengthened to ensure that staff document all required elements in response to critical values on a nursing progress note or the Nursing Critical Value Template note.
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8 We recommended that nursing managers monitor the staffing methodology that was implemented in May 2012.
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14917