Recommendations
2056
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-00117-108 | Comprehensive Healthcare Inspection of the Beckley VA Medical Center in West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs incorporate service-specific criteria in licensed independent practitioners’ Ongoing Professional Practice Evaluations.
Closure Date:
2 The Chief of Staff ensures service chiefs regularly monitor licensed independent practitioners’ performance through Ongoing Professional Practice Evaluations.
Closure Date:
3 The Medical Center 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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| 22-01275-99 | Transition to VA Health Care and Utilization of Benefits for Veterans Who Reported Sexual Assault During Military Service | National Healthcare Review | ||
1 The Under Secretary for Health examines potential differences between the veterans who reported to Sexual Assault Prevention and Response Office and used VA health care and those who did not in order to improve outreach efforts to the nearly half who did not engage with VA health care.
Closure Date:
2 The Under Secretary for Benefits evaluates the service-connected disability application and claims process for veterans who reported sexual assault that occurred during military service to identify and mitigate potential barriers.
Closure Date:
3 The Under Secretary for Benefits examines potential differences between the veterans who reported to Sexual Assault Prevention and Response Office and used VA benefits and those who did not in order to improve outreach efforts.
Closure Date:
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| 23-00528-92 | Deficiencies in Quality of Care at VA Maine Healthcare System in Augusta | Hotline Healthcare Inspection | ||
1 The VA Maine Healthcare System Director confirms that staff complete the Columbia-Suicide Severity Rating Scale and document on the Veterans Health Administration template when patients are unwilling to participate in completion of the screening.
Closure Date:
2 The VA Maine Healthcare System Director oversees a review to determine whether a VA Maine Healthcare System policy in which clinical staff will be expected to develop safety plans with patients is needed; and if so, ensures one is created.
Closure Date:
3 The VA Maine Healthcare System Director verifies that patients identified as having suicidal ideations or behaviors have personalized safety plans documented in the electronic health record, and monitors compliance.
4 The VA Maine Healthcare System Director assesses staff knowledge of when to notify the VA Maine Healthcare System suicide prevention staff about a patient who has made a threat of self-directed violence during a phone call with VA staff, and takes action as warranted.
Closure Date:
5 The VA Maine Healthcare System Director ensures that VA Maine Healthcare System leaders and root cause analysis teams are trained in the process for responding to concerns with root cause analysis team findings according to VA National Center for Patient Safety guidance, and monitors adherence.
Closure Date:
6 The VA Maine Healthcare System Director ensures that a review of the episode of care prior to the patient’s death is completed to determine whether peer reviews are warranted, and takes action accordingly.
Closure Date:
7 The VA Maine Healthcare System Director confirms that VA Maine Healthcare System leaders, risk managers, and patient safety staff have knowledge of the types of quality management reviews that can and cannot be done concurrently.
Closure Date:
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| 23-00106-94 | Comprehensive Healthcare Inspection of the Central Alabama Veterans Health Care System in Montgomery | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.
Closure Date:
2 The Chief of Staff ensures the Suicide Prevention Coordinator reports suicide-related events monthly to mental health leaders and quality management staff.
Closure Date:
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| 23-00023-96 | Comprehensive Healthcare Inspection of the Charles George VA Medical Center in Asheville, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures the Patient Safety Manager documents start dates for sentinel event investigations in the Joint Patient Safety Reporting system.
Closure Date:
2 The Director ensures the Patient Safety Manager initiates a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
Closure Date:
3 The Director ensures executive leaders consolidate all credentialing and privileging activities into one credentialing and privileging office under the Chief of Staff.
Closure Date:
4 The Director ensures the Credentialing and Privileging Manager reports directly to the Chief of Staff.
Closure Date:
5 The Director 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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| 22-01315-90 | Sterile Processing Service Deficiencies and Leaders’ Response at the Carl Vinson VA Medical Center in Dublin, Georgia | Hotline Healthcare Inspection | ||
1 The Carl Vinson VA Medical Center Director ensures that the Sterile Processing Services chief conducts comprehensive staff competency assessments for the reprocessing of reusable medical equipment, and monitors for compliance.
Closure Date:
2 The Carl Vinson VA Medical Center Director ensures that the CensiTrac Instrument Tracking System is fully implemented, and that training is provided to the CensiTrac coordinator and Sterile Processing Services staff, and monitors for compliance.
3 The Carl Vinson VA Medical Center Director evaluates and ensures that Sterile Processing Services maintains a safe and clean environment in all areas where decontamination, sterilization, or clean and sterile storage of reusable medical equipment are performed, and monitors for compliance.
Closure Date:
4 The Carl Vinson VA Medical Center Director develops an action plan for remediation of the location and use of the training room adjacent to Sterile Processing Services’ clean and sterile storage area, and monitors for compliance.
Closure Date:
5 The Carl Vinson VA Medical Center Director ensures that clinic areas, including radiology, have or share a designated soiled utility room as required by Veterans Health Administration policy, and monitors for compliance.
Closure Date:
6 The Carl Vinson VA Medical Center Director ensures that Sterile Processing Service standard operating procedures for reusable medical equipment are developed, updated consistent with manufacturer’s instructions for use, disseminated, and available at the point of use, and monitors for compliance.
Closure Date:
7 The Veterans Integrated Service Network Director reviews the facility’s Sterile Processing Service water management program and takes action as necessary to ensure compliance with Veterans Health Administration guidance, and monitors for compliance.
Closure Date:
8 The Carl Vinson VA Medical Center Director ensures that the facility Water Working Group submits critical water system test results to the Veterans Integrated Service Network Sterile Processing Services Management Board, as required, and monitors for compliance.
Closure Date:
9 The Veterans Integrated Service Network Director ensures all critical water system test results are reviewed by the Veterans Integrated Service Network Sterile Processing Services Management Board, corrective action is taken when appropriate, and all corrective actions are reported to the National Program Office for Sterile Processing, and monitors for compliance.
Closure Date:
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| 22-03157-95 | Comprehensive Healthcare Inspection of the Manchester VA Medical Center in New Hampshire | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures the Medical Executive Council reviews results of professional practice evaluations.
Closure Date:
2 The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete licensed independent practitioners’ professional practice evaluations.
Closure Date:
3 The Veterans Integrated Service Network Director ensures the Veterans Integrated Service Network Chief Medical Officer provides oversight of the medical center’s privileging process.
Closure Date:
4 The Medical Center Director ensures the Comprehensive Environment of Care Coordinator or designee schedules environment of care inspections and staff complete and document them at the required frequency.
Closure Date:
5 The Medical Center Director ensures staff keep patient care areas clean and safe.
Closure Date:
6 The Medical Center Director 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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| 22-03166-88 | Comprehensive Healthcare Inspection of the Aleda E. Lutz VA Medical Center in Saginaw, Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures staff complete individual root cause analyses for all adverse patient safety events with an actual or potential safety assessment code score of 3.
Closure Date:
2 The Chief of Staff ensures service chiefs maintain sufficient data for licensed independent practitioners’ Ongoing Professional Practice Evaluations.
Closure Date:
3 The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
4 The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.
Closure Date:
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| 23-00015-86 | Comprehensive Healthcare Inspection of the White River Junction VA Medical Center in Vermont | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures staff complete a minimum of eight patient safety analyses each year.
Closure Date:
2 The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete Focused and Ongoing Professional Practice Evaluations.
Closure Date:
3 The Chief of Staff ensures service chiefs complete licensed independent practitioners’ Ongoing Professional Practice Evaluations on a regular basis.
Closure Date:
4 The Medical Center Director ensures the suicide prevention coordinators report suicide-related events monthly to mental health leaders and quality management staff.
Closure Date:
5 The Medical Center 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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| 23-00018-83 | Comprehensive Healthcare Inspection of the Minneapolis VA Health Care System in Minnesota | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff 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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14921