All Reports

The Director takes appropriate action so staff update the facility policy for communicating test results and develop service-level workflows that describe team members’ roles in the process, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Veterans Integrated Service Network Director and facility Director take appropriate action for the surveillance system to be fully operational.

The Director takes appropriate actions to secure portable liquid nitrogen tanks and store the tanks according to the National Fire Protection Association’s Compressed Gases and Cryogenic Fluids Code, NFPA 55 requirements.

The Wm. Jennings Bryan Dorn VA Medical Center Director ensures that all patients admitted to the intensive care unit receive access to continuous critical care, particularly after hours, and clearly defines the role and responsibilities of the on-site intensivist and TeleCritical Care in the care of surgical intensive care unit admissions.

The Wm. Jennings Bryan Dorn VA Medical Center Director ensures that in the absence of patient-specific orders for vital sign parameters that warrant provider notification, intensive care unit nurses adhere to facility policy for provider notification parameters.

The Wm. Jennings Bryan Dorn VA Medical Center Director reviews VHA Directive 1155(1), Treatment of Acute Ischemic Stroke, August 22, 2025, and ensures the facility is in full compliance with current stroke center designation requirements, including protocols for inpatient stroke response, diagnostic imaging, consultation, and transfer processes.

The Wm. Jennings Bryan Dorn VA Medical Center Director clarifies the qualifications for provider coverage in the intensive care unit and ensures all intensive care unit providers are appropriately privileged to deliver care in the intensive care unit prior to providing care.

The Wm. Jennings Bryan Dorn VA Medical Center Director determines whether providers delivered patient care in the intensive care unit without approved, current, facility‑specific privileges and, if so, completes required reviews and assessments in accordance with VHA requirements.

The Wm. Jennings Bryan Dorn VA Medical Center Director creates a process ensuring contract ICU physicians covering in the intensive care unit have access to the electronic health record for documentation and order writing from the start of their tour.

The Wm. Jennings Bryan Dorn VA Medical Center Director reviews this patient’s case and any associated quality management reviews, and if gaps are identified, develops an action plan to ensure quality management processes are completed in accordance with relevant VHA quality management directives.

Facility leaders take appropriate actions so staff develop a written workflow for each service that is consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions so fire doors close completely and latch, as required by National Fire Protection Association 80 Standard for Fire Doors and Other Opening Protectives.

The Director takes appropriate actions so staff update the facility policy on test result communications to meet the requirements of Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services/Nurse Executive take appropriate actions so staff develop, for each service, written workflows consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions for the Chief of Staff to review Patient Centered Management Module data and address efficiency, capacity, and staffing needs, in accordance with Veterans Health Administration Directive 1406(3), Patient Centered Management Module (PCMM) for Primary Care.

The Director develops workflows for all services that communicate test results to patients and includes the process for assigning designees (surrogates) for providers who order tests in the facility’s policy, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services develop workflows that describe how each team member participates in the process for communicating test results.

The Associate Director keeps patient care areas clean and stores dirty and clean items separately.

The Medical Center Director develops service-level workflows for communicating test results.

The Medical Center Director monitors data on the communication of test results to providers and patients as required by VHA Directive 1088(1), Communicating Test Results to Providers and Patients.

Facility leaders ensure staff follow procedures to properly separate and store soiled and clean equipment.

Facility leaders ensure environmental management services staff clean ice machines daily to help prevent infection risk.

Facility leaders ensure staff properly label and store oxygen tanks.

Facility leaders ensure staff update the facility policy to include all elements to communicate test results to patients, as required in Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

Executive leaders ensure staff maintain a clean and safe environment.

The Medical Center Director ensures providers complete secondary toxic exposure screenings within 30 days.

The Chief of Staff ensures facility leaders develop workflows for all services to identify team members’ roles in the process for communicating test results.

The Director ensures Environmental Management Services staff keep patient care areas clean and well maintained.

Facility leaders ensure staff place signs on or near each building to help veterans easily navigate where services are located.