Recommendations
2225
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-00416-10 | Improvements Needed in Lung Cancer Screening Through Use of Community Care | National Healthcare Review | ||
1 The Under Secretary for Health evaluates whether low-dose computed tomography lung cancer screenings sent through VA community care have quality assurance practices in place that ensure timely reporting of results to VA facilities consistent with other cancer screenings that are sent through the community care program and takes corrective action to address any identified deficiencies.
Closure Date:
2 The Under Secretary for Health ensures the Veterans Health Administration Office of Integrated Veteran Care reevaluates whether the minimum number of attempts prior to administratively closing consults for community care lung cancer screening with low dose computed tomography scans should continue as an ongoing process, and takes action as warranted.
Closure Date:
3 The Under Secretary for Health reiterates expectations for providers to comply with the Veterans Health Administration directive regarding communication of test results to patients, including required time frames.
Closure Date:
4 The Under Secretary for Health evaluates whether low-dose computed tomography lung cancer screenings sent through VA community care have quality assurance practices in place that ensure follow-up on scan results consistent with other cancer screenings that are sent through the community care program and takes corrective action to address any identified deficiencies.
Closure Date:
5 The Under Secretary for Health facilitates a comprehensive review of the patient cases provided by the Office of Inspector General, assesses these patients for adverse clinical outcomes, and implements action plans as needed.
Closure Date:
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| 23-00092-12 | Comprehensive Healthcare Inspection of the James E. Van Zandt VA Medical Center in Altoona, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges evaluate licensed independent practitioners on an ongoing basis.
Closure Date:
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| 22-00237-05 | Comprehensive Healthcare Inspection of the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas | Comprehensive Healthcare Inspection Program | ||
1 The Director determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for applicable sentinel events.
Closure Date:
2 The Chief of Staff determines the reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in Ongoing Professional Practice Evaluations.
Closure Date:
3 The Director evaluates and determines any additional reasons for noncompliance and ensures staff maintain medical supplies that are not contaminated, damaged, expired, or recalled.
Closure Date:
4 The Chief of Staff or Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff post notices in treatment areas with overt recording announcing the area is subject to photography or video recording.
Closure Date:
5 The Director evaluates and determines the reasons for noncompliance and ensures staff create or update safety plans for patients with a positive suicide risk screen who are determined safe to discharge home from the Emergency Department.
Closure Date:
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| 23-00006-03 | Comprehensive Healthcare Inspection of the Royal C. Johnson Veterans' Memorial Hospital in Sioux Falls, South Dakota | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures designated staff complete a 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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| 22-03522-209 | VBA Generally Helped Veterans Obtain Damaged or Destroyed Records | Audit | ||
1 Establish a process to identify and track veterans’ files for those determined to have fire-damaged or destroyed records, such as adding a corporate flash, and update the Adjudication Procedural Manual indicating when veterans service representatives should apply such procedures.
Closure Date:
2 Instruct veterans service representatives on the process for requesting service treatment and military service records for fire-related records, which includes more specific guidance on what information is required for the National Personnel Records Center to locate veterans’ records.
Closure Date:
3 Ensure veterans service representatives are made aware of and follow steps as outlined in the manual for when to send required forms and conduct follow-up contact with veterans.
Closure Date:
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| 23-00080-227 | Deficiencies in Facility Leaders’ Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas | Hotline Healthcare Inspection | ||
1 The Houston VA Medical Center Director ensures that staff conduct and document focused professional practice evaluations for cause as required by the Veterans Health Administration.
Closure Date:
2 The Houston VA Medical Center Director reviews processes for reporting providers to state licensing boards and the national practitioner data bank when a concern for patient safety is identified, and takes action to ensure compliance.
Closure Date:
3 The Houston VA Medical Center Director reviews the processes for conducting root cause analyses to ensure that reports are completed timely and that action plans are measurable, sustainable, and monitored to completion.
Closure Date:
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| 22-03247-198 | VHA Should Continue to Improve Water Safety and Oversight of Prevention Practices to Minimize the Effects of Legionella | Audit | ||
1 The assistant under secretary for health for support should establish certification procedures for Veterans Integrated Service Networks to ensure medical facilities’ healthcare-associated Legionella disease prevention plans for buildings comply with Veterans Health Administration Directive 1061 requirements.
Closure Date:
2 The assistant under secretary for health for support should develop and ensure Veterans Integrated Service Networks perform and document quality control and quality assurance checks of their requirements for oversight and enforcement of the Veterans Health Administration Directive 1061 quarterly Legionella water testing procedures conducted by the facility.
Closure Date:
3 The assistant under secretary for health for operations should monitor Veterans Integrated Service Network officials fulfillment of their oversight responsibilities found in Veterans Health Administration Directive 1061 regarding Legionella water sampling, testing, remediation efforts, and reporting of Legionella water testing data, including the post-remediation test results.
Closure Date:
4 The director of the Office of Healthcare Engineering should consider alternative measures, such as adding dedicated resources, to provide expertise and support for medical facilities experiencing persistent positive Legionella in facility water supply systems after applying the remediation efforts prescribed by Veterans Health Administration Directive 1061.
Closure Date:
5 The director of the Office of Healthcare Engineering should assist the Salem VA medical center with their persistent positive Legionella in the facility water supply system, and, with consideration of the ongoing water supply system renovations, develop an action plan to mitigate remediation challenges.
Closure Date:
6 The director of the Office of Healthcare Engineering should clarify the responsibility section of Veterans Health Administration Directive 1061 to clearly define oversight responsibilities for ensuring required remediation steps are completed when facilities received positive Legionella water test results.
Closure Date:
7 The director of the Office of Healthcare Engineering should revise the Water Safety Management Tool to alert Veterans Integrated Service Network and medical facility oversight officials when quarterly testing data is not posted.
Closure Date:
8 The assistant under secretary for health for operations should take actions to confirm that Veterans Integrated Service Network officials are ensuring front-line staff are routinely notified by responsible medical facility officials when elevated Legionella water sample levels require diagnostic awareness and additional clinical surveillance of veterans to detect Legionnaires’ disease.
Closure Date:
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| 22-00073-223 | Comprehensive Healthcare Inspection of the Alexandria VA Health Care System in Pineville, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs complete Focused Professional Practice Evaluations.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs consistently review Ongoing Professional Practice Evaluation data.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete the Comprehensive Suicide Risk Evaluation following a positive suicide risk screen and include an assessment of whether the current suicidal ideation was the most severe in the last 30 days.
Closure Date:
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| 22-00074-218 | Comprehensive Healthcare Inspection of the Gulf Coast Veterans Health Care System in Biloxi, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures leaders follow their defined governance structure.
Closure Date:
2 The Chief of Staff determines any additional reasons for noncompliance and ensures leaders use service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
3 The Chief of Staff determines any additional reasons for noncompliance and ensures service chiefs maintain Ongoing Professional Practice Evaluation data in licensed independent practitioners’ privileging folders.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete professional practice evaluations of licensed independent practitioners.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Executive Committee of the Medical Staff reviews the service chiefs’ recommendations along with clinical competence information when making privileging recommendations for licensed independent practitioners.
Closure Date:
6 The System Director determines any additional reasons for noncompliance and ensures staff maintain a clean and safe environment.
Closure Date:
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| 22-00076-222 | Comprehensive Healthcare Inspection of the Central Arkansas Veterans Healthcare System in Little Rock | Comprehensive Healthcare Inspection Program | ||
1 The Director determines the reasons for noncompliance and ensures staff complete an individual root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define time frames for Focused Professional Practice Evaluations.
Closure Date:
3 The Director evaluates and determines any additional reasons for noncompliance and ensures clinicians complete a Comprehensive Suicide Risk Evaluation following a positive suicide risk screen for patients seen in the Emergency Department.
Closure Date:
4 The Director evaluates and determines any additional reasons for noncompliance and ensures clinicians create or update a suicide safety plan for patients determined to be at intermediate, high-acute, or chronic risk-for-suicide and safe to discharge home from the Emergency Department.
Closure Date:
5 The Director evaluates and determines any additional reasons for noncompliance and ensures clinicians follow up within seven days with patients determined to be at intermediate, high-acute, or chronic risk-for-suicide who were discharged home from the Emergency Department.
Closure Date:
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15770