Recommendations
2062
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-03544-111 | Community Care Departments Need Reliable Staffing Data to Help Address Challenges in Recruiting and Retaining Staff | Audit | ||
1 Implement consistent data entry, standardized organizational codes, and periodic reviews for HR Smart community care data.
Closure Date:
2 Develop staffing reports that can be searched by service departments to ensure appropriate resources to meet their assigned missions.
Closure Date:
3 Improve usability of the staffing assessment tool by implementing policy to address the inconsistencies with staffing data entry and review the reported data for accuracy.
4 Assess whether consolidated community care units would more broadly support veterans’ access to community care and help mitigate the impact of staffing shortages, and, if so, develop a project management plan for implementing those units.
Closure Date:
5 Assess the use of monetary and nonmonetary incentives to evaluate whether they are effective in recruiting and retaining administrative staff within community care departments.
Closure Date:
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| 22-04099-153 | Review of VISN 10 and Facility Leaders’ Response to Recommendations from a VHA Office of the Medical Inspector Report, John D. Dingell VA Medical Center in Detroit, Michigan | Hotline Healthcare Inspection | ||
1 The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director evaluates and ensures all Veterans Integrated Service Network 10 facilities comply with Veterans Health Administration requirements regarding resident supervision, specifically related to post-graduate year one on-site direct supervision.
2 The John D. Dingell VA Medical Center Director reviews the March 2023 National Surgery Office program review as referenced in the Office of the Medical Inspector report and ensures a comprehensive and sustainable response to the recommendations noted in the National Surgery Office memorandum.
Closure Date:
3 The John D. Dingell VA Medical Center Director and facility leaders meet all Veterans Health Administration requirements for National Practitioner Data Bank and State Licensing Board reporting for healthcare providers that meet reporting criteria.
Closure Date:
4 The John D. Dingell VA Medical Center Director ensures the chief of surgery facilitates and provides oversight of morbidity and mortality conferences.
Closure Date:
5 The John D. Dingell VA Medical Center Director ensures that initial level 3 peer review results of Peer Review Committee members’ cases are reassessed by another neutral VA facility Peer Review Committee for final level determination.
Closure Date:
6 The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director ensures the Veterans Integrated Service Network academic affiliations officer maintains awareness of and performs assigned roles and responsibilities per Veterans Health Administration requirements.
Closure Date:
7 The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director ensures the Veterans Integrated Service Network surgical workgroup reviews applicable Veterans Health Administration policies, and documents discussion and action plans to reflect facilities’ compliance with Veterans Health Administration policy and surgical complexity level.
Closure Date:
8 The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director provides continued oversight and structured support to executive and service line leaders during key leader transitions, and monitors actions taken to ensure completion of action plans.
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9 The John D. Dingell VA Medical Center Director reviews organizational communication channels and ensures consistency with Veterans Health Administration High Reliability Organization goals and considers the use of Veterans Health Administration resources such as the Veterans Health Administration National Center for Organization Development.
Closure Date:
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| 22-04104-112 | Inspection of Information Security at the Northern Arizona VA Healthcare System | Information Security Inspection | ||
1 Implement a more effective vulnerability management program to address security deficiencies identified during the inspection.
Closure Date:
2 Ensure vulnerabilities are remediated within established time frames.
3 Implement more effective configuration control processes to ensure network devices maintain vendor support.
Closure Date:
4 Ensure the unmanaged database completes the transition to the VA Enterprise Cloud where it can be managed and have security baselines applied.
Closure Date:
5 Implement an improved inventory process to ensure that all connected devices used to support VA programs and operations are documented in the Enterprise Mission Assurance Support Service.
Closure Date:
6 Ensure network infrastructure equipment is properly installed.
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7 Ensure physical access controls are implemented for communication rooms.
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8 Ensure a video surveillance system is operational and monitored for the data center.
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9 Ensure communication rooms with infrastructure equipment have adequate environmental controls.
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10 Ensure communication rooms with infrastructure equipment have fire-detection and suppression systems.
Closure Date:
11 Ensure water detection sensors are implemented in the data center.
Closure Date:
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| 22-01540-146 | Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri | Hotline Healthcare Inspection | ||
1 The VA St. Louis Health Care System Director conducts a fact-finding investigation asnecessary to determine whether the chief of the Emergency Department’s conduct wasinconsistent with VA policy and federal regulations and takes action as appropriate.
Closure Date:
2 The VA St. Louis Health Care System Director establishes a standardized process for theadministration of the Columbia-Suicide Severity Rating Scale by Emergency Department staff topatients to maintain the integrity of the suicide risk screen.
Closure Date:
3 The VA St. Louis Health Care System Director establishes a formal policy outliningexpectations for the monitoring of patients by Emergency Department nursing staff after triage.
Closure Date:
4 The VA St. Louis Health Care System Director ensures root cause analyses and administrativeinvestigations are conducted efficiently and effectively if chartered for the same event as perVeterans Health Administration policy.
Closure Date:
5 The VA St. Louis Health Care System Director ensures that institutional disclosures arecompleted within the time frame required by the Veterans Health Administration.
Closure Date:
6 The VA St. Louis Health Care System Director ensures compliance with the Veterans HealthAdministration requirement for reporting healthcare professionals to the appropriate statelicensing board when indicated.
Closure Date:
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| 22-00051-136 | Comprehensive Healthcare Inspection of the Phoenix VA Health Care System in Arizona | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.
Closure Date:
2 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Protected Peer Review Committee recommends improvement actions for all Level 3 peer reviews.
Closure Date:
3 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board reviews the Protected Peer Review Committee’s summary analysis quarterly.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs establish service-specific criteria for professional practice evaluations.
Closure Date:
5 The Executive Director determines the reasons for noncompliance and ensures staff conduct environment of care inspections in patient care areas at the required frequency.
Closure Date:
6 The Executive Director determines the reasons for noncompliance and ensures staff post signage to indicate areas that are subject to video recording.
Closure Date:
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| 22-03503-131 | Financial Efficiency Inspection of the VA Philadelphia Healthcare System | Financial Inspection | ||
1 Ensure that healthcare system finance office staff are made aware of all VA financial policy requirements in the review and management of inactive open obligations, and deobligate any identified excess funds.
Closure Date:
2 Ensure cardholders comply with VA financial policy record retention requirements
Closure Date:
3 Establish controls to confirm approving officials and purchase cardholders review purchases for VA policy compliance and ensure contracting is used when it is in the best interest of the government.
Closure Date:
4 Require purchase cardholders to submit a request for ratification for any unauthorized commitments identified.
Closure Date:
5 Ensure the chief supply chain officer establishes local processes and procedures so that all necessary reports are routinely monitored on the Supply Chain Common Operating Picture, the Generic Inventory Package, or other inventory sites or software systems to ensure performance measures are maintained, as required in the Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.
Closure Date:
6 Ensure supply chain managers implement a plan for staff training to increase awareness of internal controls and data reliability issues, such as conversion factor, within the Generic Inventory Package.
Closure Date:
7 Ensure the chief of supply chain services provides quarterly physical inventory memoranda of “A” classified items to Veterans Integrated Service Network personnel, as required in the Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.
Closure Date:
8 Ensure the chief supply chain officer reviews the facility item master file edit access list of all individuals at the VA medical facility who have permissions to enter or modify data within the item master file each calendar year, as required in the Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.
Closure Date:
9 Develop formalized processes for monitoring and achieving identified efficiency targets and use available pharmacy data to make business decisions.
Closure Date:
10 Establish measures to improve compliance with the VA directive to avoid end-of-year pharmaceutical purchases.
Closure Date:
11 Develop a plan to align inventory management practices, such as the use of handheld scanners, bar code labeling, and ABC inventory analysis methodology with VHA policy.
Closure Date:
12 Establish processes to ensure compliance with the Veterans Health Administration directive to complete the B09 reconciliation process.
Closure Date:
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| 22-00062-139 | Comprehensive Healthcare Inspection of the VA Southern Nevada Healthcare System in North Las Vegas | Comprehensive Healthcare Inspection Program | ||
1 The Director evaluates and determines additional reasons for noncompliance and ensures leaders evaluate sentinel events and conduct institutional disclosures when criteria are met.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with similar training and privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
3 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures electrical receptacles and switches in the mental health unit are covered by metal plates, secured by tamper-resistant screws, and receptacles are flush to the wall.
Closure Date:
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| 22-02725-132 | Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas | Hotline Healthcare Inspection | ||
1 The VA Southern Nevada Healthcare System Director reviews processes in place to ensure proper response to future medical emergencies in outpatient clinics to include staff training, emergency notification systems, and emergency documentation processes.
Closure Date:
2 The VA Southern Nevada Healthcare System Director reviews the process for and compliance with documentation of cardiopulmonary resuscitation in outpatient clinic settings, and takes action as indicated.
Closure Date:
3 The VA Southern Nevada Healthcare System Director works with outpatient clinic leaders to ensure that all deficiencies identified in the after-action plan are completed and that compliance is monitored.
Closure Date:
4 The VA Southern Nevada Healthcare System Director consults with Office of General Counsel’s Regional Counsel to review the incident and determine if an institutional disclosure is warranted and takes action accordingly.
Closure Date:
5 The VA Southern Nevada Healthcare System Director completes an evaluation of staffs’ understanding of advance care planning, advance directives, and life-sustaining treatment decision processes, and takes action to address identified gaps.
Closure Date:
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| 22-00044-142 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 17: VA Heart of Texas Health Care Network in Arlington | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer determines any additional reasons for noncompliance and reviews the credentials file and makes a recommendation on continuing the appointment process for physicians with a potentially disqualifying licensure action.
Closure Date:
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| 21-02110-138 | Review of Clinical Care Transition from the Department of Defense to the Veterans Health Administration for Service Members with Opioid Use Disorder | National Healthcare Review | ||
1 The Under Secretary for Health directs the Office of Primary Care and Office of Mental Health and Suicide Prevention to identify barriers to provider documentation of opioid use disorder in progress notes and implement solutions addressing these barriers.
Closure Date:
2 The Under Secretary for Health ensures the Office of Primary Care and Office of Mental Health and Suicide Prevention determine impediments to maintaining accurate identification of opioid use disorder in electronic health record problem lists and implement policy and training to support accurate use of problem lists.
3 The Under Secretary for Health confirms the Office of Primary Care and Office of Mental Health and Suicide Prevention evaluate barriers affecting provider access and use of Department of Defense treatment records in Joint Longitudinal Viewer and implement solutions.
4 The Under Secretary for Health ensures the Office of Primary Care and Office of Mental Health and Suicide Prevention improve continuity of care by confirming providers are educated on the navigation and retrieval of Department of Defense treatment records in Joint Longitudinal Viewer.
5 The Under Secretary for Health requires the Assistant Under Secretary for Health for Clinical Services/Chief Medical Officer to evaluate and update processes for identification of veterans with a history of opioid use disorder for the provision of opioid overdose risk mitigation strategies.
Closure Date:
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14943