All Reports

Facility leaders ensure staff have access to sinks or hand hygiene supplies in or near soiled utility rooms that store biohazardous materials.

Facility leaders assess how staff monitor video laryngoscope supplies to ensure they are readily available, and staff remove supplies when they expire.

Facility leaders ensure staff develop service-level workflows for the communication of test results per the VHA directive.

Executive leaders ensure staff post safety risk assessment permits for all construction projects.

The Director assigns a member of the executive leadership team as chair of the Construction Safety Committee to oversee safety activities.

Executive leaders ensure staff install privacy curtains in all exam rooms.

Executive leaders ensure staff install handrails on both sides of the hallway in the Community Living Center.

Executive leaders ensure staff follow the facility’s policy for communication of abnormal test results to patients.

The Associate Director for Operations ensures staff keep patient care areas clean and clean storage areas free of dirty items and equipment.

The Chief of Staff ensures the facility has workflows for all services to identify team members’ roles in the test result communication process.

The VA Detroit Healthcare System Director ensures pathology and laboratory medicine service leaders communicate feedback regarding staff-specific errors to facilitate staff learning and according to Veterans Health Administration high reliability organization guidance.

The VA Detroit Healthcare System Director evaluates the quality and patient safety service response to patient safety events, including tracking and monitoring of service level corrective action plans to ensure timely resolution of patient safety events, and takes action as necessary.

The VA Detroit Healthcare System Director verifies pathology and laboratory medicine service leaders demonstrate clear communication of the laboratory quality management technologist roles and responsibilities in accordance with Veterans Health Administration requirements.

The VA Detroit Healthcare System Director ensures the pathology and laboratory medicine service will sustain oversight of manual complete blood count with differential reads for accuracy via retrospective pathologist secondary reviews.

The VA Detroit Healthcare System Director makes certain that pathology and laboratory medicine service leaders track variance reporting and ensure completion of applicable corrective action in accordance with facility policy and Veterans Health Administration requirements.

The Director, National Teleradiology Program ensures guidance in memoranda of understanding, teleradiology service agreements, and policies related to the entity responsible for the completion of National Teleradiology Program radiologist peer reviews is consistent and aligns with Veterans Health Administration requirements.

The Director, National Teleradiology Program reviews the barriers, to include staffing shortages, to achieving turnaround time goals and creates a plan of action to optimize results.

The Director, National Teleradiology Program, in cooperation with Veterans Health Administration’s National Radiology Program, explores additional options for the recruitment and retention of National Teleradiology Program radiologists.

The Under Secretary for Health, in cooperation with Veterans Health Administration’s National Radiology Program, reviews the tools available for the recruitment and retention of radiologists across the Veterans Health Administration and creates a plan of action to optimize filling vacant positions.

The Under Secretary for Health ensures all facilities with an agreement for service by the National Teleradiology Program have a contingency plan.

The Executive Director ensures each service has a service-level workflow for test result communication.

The Executive Director reviews current practices to obtain documents from community providers and determines if leaders can standardize an approach to improve timeliness.

The Lexington VA Healthcare System Director ensures emergency department, mental health, and inpatient medical and nursing staff responsible for suicide risk assessment understand the need to evaluate patients for a personally owned insulin pump and remove the insulin pump prior to inpatient admission, when necessary and monitors for compliance.

The Lexington VA Healthcare System Director verifies the draft insulin pump policy is finalized, and Lexington VA Healthcare System emergency department, mental health, and inpatient medical and nursing staff are educated on the policy.

The Lexington VA Healthcare System Director ensures leaders and staff review the Lexington VA Healthcare System policy evaluation and approval procedure.

The Lexington VA Healthcare System Director verifies that patients receive discharge instructions, with a follow-up care plan when discharged from the Lexington VA Healthcare System emergency department.

The Lexington VA Healthcare System Director ensures a review of Psychiatrist 2’s documentation in Patient 2’s electronic health record and makes certain documentation is completed according to Veteran Health Administration policy, including that entries are accurate, succinct, without extensive copy and paste, and devoid of derogatory, critical, comments, and takes action as warranted.

The Lexington VA Healthcare System Director confirms that the patient safety managers understand and apply Veteran Health Administration guidance to accurately use safety assessment codes when scoring a patient safety event.

The Lexington VA Healthcare System Director verifies that root cause analyses are completed according to Veterans Health Administration policy including interviewing individuals knowledgeable about the event.

The Lexington VA Healthcare System Director ensures peer representation at the Peer Review Committee for psychiatry case reviews.

The VA Greater Los Angeles Healthcare System Director considers conducting peer reviews for the clinical staff involved in the patient’s care from day 30 through day 32, to identify opportunities to strengthen clinical practices and improve the quality of patient care.

The VA Greater Los Angeles Healthcare System Director ensures that inpatient nurses receive training on the National Early Warning Signs assessment related to the assessment’s administration, intervention, escalation, and documentation; establishes a process to monitor inpatient nurses’ adherence; and conducts audits to ensure improved and sustained compliance.

The VA Greater Los Angeles Healthcare System Director ensures nursing staff have knowledge of and timely access to the accurate names and contact numbers for patients’ on-call provider teams and the medical officer of the day, and addresses and closely monitors discrepancies as warranted.

The VA Greater Los Angeles Healthcare System Director reviews [Standard Operating Procedure] SOP-00-QM-100, Clinical and Administrative Escalation Process, May 28, 2025; ensures the procedure meets facility and service-line needs; and confirms information is disseminated to relevant leaders, providers, and nursing staff.

The VA Greater Los Angeles Healthcare System Director ensures nursing shift assessments electronic health record documentation is completed, timely, and at frequencies required by Veterans Health Administration’s nursing policies and procedures; takes corrective action as indicated; and establishes a process to monitor for improved and sustained compliance.

The VA Greater Los Angeles Healthcare System Director evaluates the circumstances surrounding the death of the patient to ensure completion of comprehensive quality review process(es) in alignment with Veterans Health Administration standards on patient safety and high reliability that identify root causes and provide actions that enhance patient safety and mitigate similar events.

The VA Greater Los Angeles Healthcare System Director confirms that facility staff made reasonable efforts to conduct an institutional disclosure with the patient’s family.

The Executive Director oversees improvements to the telephone system to ensure identified vulnerabilities are addressed.

Facility leaders ensure exit signs lead to an exit.

Facility leaders install detectable warning surfaces anywhere a walkway transitions into a roadway.

The Executive Director ensures staff keep patient care areas clean and safe.

Facility leaders ensure staff conduct a risk assessment for electrical cord management to identify and implement any needed improvements.

The Executive Director ensures staff post biological hazard signs on doors where potentially infectious materials may be present and store clean and dirty items separately.

The Executive Director ensures prompt disposal of biohazardous waste.

Facility leaders ensure staff conduct a risk assessment on liquid nitrogen use and storage, to include devices in exam rooms, and implement changes accordingly.

The Executive Director ensures the Comprehensive Environment of Care Committee identifies at least one facility-specific environment of care trend and establishes a performance improvement plan, including outcome measures, to address it.

Facility leaders ensure staff develop service-level workflows for the communication of test results for each service.

Facility leaders review the test result communication policy to ensure it complies with the VHA requirement for communicating critical results outside of normal business hours.

Facility leaders develop a formal process for staff to track performance metrics for test result communication, implement improvement actions, and report compliance to an appropriate oversight committee.

Facility leaders manage panel sizes to ensure patients have timely access to high-quality care.

Executive leaders ensure staff fix or replace damaged furnishings to allow effective cleaning and disinfection.

Executive leaders ensure staff place paper maps at information desks to assist veterans in navigating the facility.

Executive leaders ensure staff store clean equipment in a sanitary environment.

Executive leaders ensure hallways and exits are free from obstruction.

Executive leaders ensure staff remove defective equipment from clinical areas to prevent use.

Executive leaders ensure staff have computer screen privacy filters to protect patients’ personally identifiable information.

Facility leaders ensure staff follow facility policies and maintain a cleanenvironment.

Facility leaders ensure staff develop service-level workflows for the communication of urgent, noncritical test results.

Executive leaders monitor the effectiveness of the patient notification process.

The VA New York Harbor Healthcare System Director reviews facility processes to ensure medical and psychosocial health care for residents who report abuse, and staff are educated on the requirements.

The VA New York Harbor Healthcare System Director ensures that community living center nursing leaders and factfinding investigators complete factfindings in accordance with Veterans Health Administration policy.

The VA New York Harbor Healthcare System Director reviews responses to other incidents of suspected abuse and ensures actions are completed for resolution, including notifications.

The VA New York Harbor Healthcare System Director ensures community living center staff are compliant with Veterans Health Administration Prevention and Management of Disruptive Behavior Program education and training requirements.

The VA New York Harbor Healthcare System Director ensures community living center nursing and clinical staffs’ electronic health records documentation meets requirements for timeliness, accuracy, and completion, and takes action as needed.

The Under Secretary for Health ensures that VHA abuse policy addresses compliance with federal statutes and regulations, including 42 C.F.R. § 483.12, and outlines suspected elder abuse processes to notify leaders, interdisciplinary care team members, VA Police, patients’ families or designees, and state regulatory agencies; and identifies roles and responsibilities of reviewing officials for investigative reviews.

The VA New York Harbor Healthcare System Director ensures system abuse policies include required elements to comply with Veterans Health Administration, state, and federal regulations, including 42 C.F.R. § 483.12; and clearly outlines processes for leaders and staff when responding to suspected abuse related to reporting (for example, to interdisciplinary care team members, VA Police, family or designee, and state regulatory agencies); and conducting factfinding investigations.

The VA Fayetteville Coastal Healthcare System Director reviews the endocrine consult management process and takes actions as needed to ensure compliance with current Veterans Health Administration directives and guidance.

The VA Fayetteville Coastal Healthcare System Director implements a strategy to review patients affected by delayed endocrine consults to evaluate whether harm occurred and the appropriateness of institutional disclosures.

The VA Fayetteville Coastal Healthcare System Director ensures a sustainable and effective service line agreement between endocrine and primary care services is developed and agreed upon by both services, and monitors implementation.

The VA Fayetteville Coastal Healthcare System Director confirms effective utilization of endocrine clinic appointments to ensure timely access to care.

The VA Fayetteville Coastal Healthcare System Director ensures a process is in place for monitoring and tracking clinic profile modification requests.

The VA Mid-Atlantic Health Care Network Director reviews the leadership performance of the chief of medicine related to communication and collaboration and takes action as necessary.

The VA Fayetteville Coastal Healthcare System Director evaluates communication gaps identified in this report between leaders of primary care and the Medicine Service and takes action to ensure consistency with Veterans Health Administration High Reliability Organization goals.

Executive leaders ensure there are clear signs during construction projects, and maps at the main entrance information desk to help veterans navigate the facility.

The Medical Center Director ensures contractors inspect and test emergency generators and fire doors as required, and staff report compliance to an environment of care committee.

The Medical Center Director ensures an environment of care committee meets, as required.

The Associate Director of Patient Care Services/Nurse Executive ensures nursing staff monitor proper food clean-up, storage, and disposal in the Mental Health Residential Rehabilitation Treatment Program’s areas.

The Medical Center Director ensures staff refill hands-free sanitizer dispensers throughout the facility.

The Medical Center Director ensures the emergency management plan includes guidance for managing shelter-in-place supplies.

Executive leaders ensure staff develop service-level workflows for the communication of test results for each service.

The Medical Center Director ensures staff implement a process to monitor providers’ compliance with communicating abnormal test results to patients.

Executive leaders ensure staff complete improvement actions from root cause analyses within one year.

Facility leaders ensure providers who order tests communicate the results to patients timely.

Facility leaders identify barriers to providers completing toxic exposure screenings and implement actions to ensure providers complete screenings within 30 days of initiation.

Facility leaders ensure each service has a service-level workflow for test result communication that is consistent with VHA requirements.

The Director ensures the Chief of Staff attends Peer Review Committee meetings.

The Medical Center Director ensures staff store clean and soiled utility items separately, maintain cleanliness, and dispose of expired items.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs take action to address concerns substantiated in factfindings, and that all patient safety concerns identified in factfindings are reviewed and addressed.

The VA Southern Nevada Healthcare System Director evaluates the need for additional factfinders, and takes action as warranted.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs take action timely when aware of patient safety concerns.

The VA Southern Nevada Healthcare System Director reviews the information outlined in this report, determines the need to initiate the state licensing board reporting process, and takes action as warranted.

The VA Southern Nevada Healthcare System Director requires clinical service chiefs and credentialing and privileging managers to receive education on the completion of provider exit review forms and that, when supervisory staff contact credentialing and privileging staff for initiation of the state licensing board reporting process, a process is in place to ensure the message is clear and received.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs and staff are educated on the need and process for submitting Joint Patient Safety Reporting reports upon awareness of patient safety events in accordance with facility policy.

The VA Southern Nevada Healthcare System Director educates the Chief of Staff on the need to complete management reviews when warranted, ensures that a review occurs of the dental hygienist’s care of Patient C, and ensures disclosure is provided if warranted.

The VA Southern Nevada Healthcare System Director makes certain that the Chief of Staff utilizes high reliability organization principles and establishes a process for the communication of pervasive concerns regarding a provider’s care.