All Reports

The Deputy Secretary ensures mitigation of the high-risk pharmacy-related patient safety issues identified during the May 2021 National Center for Patient Safety visit.

The Under Secretary for Health evaluates whether the new electronic health record reflects accurate patient medication information per Veterans Health Administration requirements and takes action as indicated.

The Deputy Secretary ensures the resolution of pharmacy-related usability issues identified in this report.

The Deputy Secretary ensures correction of inaccurate medication data transmitted to the Health Data Repository.

The Under Secretary for Health determines the need for and implements a comprehensive strategy to review patients affected by inaccurate medication data transmitted to the Health Data Repository to evaluate whether harm occurred, the need for patients to undergo testing or treatment, and the appropriateness of institutional disclosures.

The Under Secretary for Health ensures patients affected by inaccurate medication data transmitted to the Health Data Repository are notified of the risk of harm per Veterans Health Administration requirements.

The Under Secretary for Health ensures legacy site providers are aware of mitigations needed for patients previously treated at a new electronic health record site and monitors compliance.

The Under Secretary for Health ensures that pharmacist staffing levels are assessed and addressed prior to the implementation of the new electronic health record at additional VA sites

The Under Secretary for Health evaluates the underlying technical and functional issues resulting in workarounds and educational materials needed to perform pharmacy-related operations within the new electronic health record and takes action as indicated.

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.

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.

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.

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.

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.

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.

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.

The Director ensures the Patient Safety Manager documents start dates for sentinel event investigations in the Joint Patient Safety Reporting system.

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.

The Director ensures executive leaders consolidate all credentialing and privileging activities into one credentialing and privileging office under the Chief of Staff.

The Director ensures the Credentialing and Privileging Manager reports directly to the Chief of Staff.

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.

The Chief of Staff ensures the Medical Executive Council reviews results of professional practice evaluations.

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete licensed independent practitioners’ professional practice evaluations.

The Veterans Integrated Service Network Director ensures the Veterans Integrated Service Network Chief Medical Officer provides oversight of the medical center’s privileging process.

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.

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

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.

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.

The Chief of Staff ensures service chiefs maintain sufficient data for licensed independent practitioners’ Ongoing Professional Practice Evaluations.

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.

The Medical Center Director ensures staff complete a minimum of eight patient safety analyses each year.

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete Focused and Ongoing Professional Practice Evaluations.

The Chief of Staff ensures service chiefs complete licensed independent practitioners’ Ongoing Professional Practice Evaluations on a regular basis.

The Medical Center Director ensures the suicide prevention coordinators report suicide-related events monthly to mental health leaders and quality management staff.

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.

The Associate Director ensures staff keep areas used by patients clean and orderly.

The Associate Director ensures staff store clean and dirty equipment and supplies separately.

The Associate Director ensures staff place all examination tables with the foot facing away from the door.

The Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to mental health leaders and quality management staff.

The Chief of Staff ensures service chiefs use service-specific criteria in the professional practice evaluations of licensed independent practitioners.

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete professional practice evaluations.

The Executive Medical Center Director ensures the Comprehensive Environment of Care Coordinator schedules, and staff complete and document, environment of care inspections at the required frequency.

The Executive Medical Center Director ensures staff document police response times to panic alarm testing in the mental health inpatient unit.

The Executive Medical Center Director ensures appropriate personnel install over-the-door alarms for sleeping room doors in the mental health inpatient unit.

The Executive Medical Center Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on sleeping room doors in the mental health inpatient unit.

The Executive Medical Center Director ensures staff maintain a safe environment in the mental health inpatient unit.

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

The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation on the same calendar day as a positive suicide risk screen, when logistically feasible and clinically appropriate, for all ambulatory care patients.

The Chief of Staff ensures the Suicide Prevention Coordinator conducts, tracks, and reports a minimum of five suicide prevention outreach activities monthly.

The Montana VA Health Care System Medical Center Director ensures that all providers, including the Chief of Staff, practice within their approved privileges.

The Under Secretary for Health ensures review of Veterans Health Administration maternity care directives to determine if more specific guidance on the limitations of pregnancy care at VA facilities is necessary to ensure that pregnant patients receive maternity care according to evidence-based practice standards, and ensures guidance is updated as warranted.

The Montana VA Health Care System Medical Center Director ensures adherence to Veterans Health Administration and facility policies for pregnancy care.

The Montana VA Health Care System Medical Center Director ensures subject matter expert review of endometrial ablation procedures performed by the facility Chief of Staff to determine whether standards of care were followed for clinical indications, patient selection, and preoperative evaluation for patients who underwent endometrial ablation, and determine whether clinical disclosures or additional patient follow-up is indicated.

The Rocky Mountain Network Director ensures processes are in place to support facilities’ external review process for ongoing professional practice evaluations in cases requiring external review by Veterans Health Administration policy and monitors compliance.

The Montana VA Health Care System Medical Center Director ensures adherence to all VHA and facility policies pertaining to privileging and re-privileging of providers including the Chief of Staff.

The Montana VA Health Care System Medical Center Director conducts a comprehensive review of the facility ongoing professional practice evaluation processes to ensure compliance with Veterans Health Administration and facility policy, and takes action as warranted.

The Rocky Mountain Network Director ensures a process is in place to monitor for timely completion of administrative actions for members of facility executive leadership team when appropriate, identifies noncompliance, and takes action as warranted.

The Rocky Mountain Network Director conducts a review of the state licensing board reporting processes at the facility to ensure compliance with Veterans Health Administration policy, identifies noncompliance, and takes action as warranted.

The Montana VA Health Care System Medical Center Director considers subject matter expert findings from the retrospective review of care provided by the Chief of Staff, determines whether clinical or institutional disclosures or additional patient follow-up is indicated, and takes action as warranted.

The Director ensures staff have written procedures for responding to utility system disruptions.

The Director ensures staff identify, minimize, or eliminate safety and security risks in the physical environment.

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.

The Director ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.

The Network Director determines the reasons for noncompliance and ensures the Patient Safety Officer collects, analyzes, and acts on peer review summary data.

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.

The Director ensures staff track deficiencies identified during comprehensive environment of care inspections through resolution.

The Director ensures staff maintain a safe and clean environment.

The Under Secretary for Health consider identifying a national program office to be responsible for oversight of alcohol withdrawal management across inpatient settings.

The Under Secretary for Health ensures the identified national program office responsible for oversight of alcohol withdrawal management consider requiring the development and implementation of written guidance for the management of alcohol withdrawal across all inpatient settings, to include: (a) expectations for determining alcohol withdrawal severity, level of care, and when transfer of care is indicated; (b) expected actions of nurses to communicate with prescribers based on patients’ changes in symptoms or alcohol withdrawal severity and when that communication should be followed by a prescribers face-to-face evaluation of a patient; (c) expectations for the evaluation of co-occurring conditions, expert consultation, and pharmacotherapy approaches; and (d) expectations for the collection and monitoring of outcome data for inpatient management of alcohol withdrawal at the national and healthcare system level.

The Under Secretary for Health consider the implementation of training for inpatient staff on the administration of standardized alcohol withdrawal severity scales.

The Under Secretary for Health initiates a review of the surgeon’s eligibility to participate in VA’s Community Care Network given Optum’s lack of documentation of their review of the surgeon’s credentialing file and takes action, as indicated.

The Under Secretary for Health reviews community care network contracts and considers modifying contracts to ensure that voluntary relinquishments and surrenders of licenses for disciplinary reasons are disqualifying for participation in VA’s Community Care Network consistent with the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act.

The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures Optum’s sufficient review and discussion of community care network providers’adverse credentialing files and monitors for compliance.

The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures that Optum documents community care network provider credentialing decisions asrequired and monitors for compliance.

The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures that Optum complies with community care contract provisions to provide Integrated Veteran Care with accreditation and credentialing documentation in accordance with federal privacy laws and VA’s community care network contract.

The Office of Integrated Veteran Care Executive Director, Integrated External Networks verifies that providers identified on the 2021 Government Accountability Office list are eligible to provide care in the VA Community Care Network.

The VA Heartland Network Director initiates a review of all community care provided by the surgeon.

The VA Marion Health Care System Director ensures primary care and patient safety staff receive education on their responsibility for Joint Patient Safety Reporting and follow-up of patient safety events related to community care, and monitors compliance with patient safety event reporting and follow-up.

The Executive Director ensures staff complete peer reviews for unanticipated deaths occurring within 24 hours of admission.

The Chief of Staff ensures service chiefs complete Ongoing Professional Practice Evaluations for licensed independent practitioners.

The Chief of Staff ensures providers with equivalent specialized training and similar privileges complete Focused Professional Practice Evaluations for licensed independent practitioners.

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same calendar day, when it is clinically appropriate, following a positive suicide risk screen.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs complete Focused Professional Practice Evaluations for all licensed independent practitioners.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete licensed independent practitioners’ professional practice evaluations.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in licensed independent practitioners’ professional practice evaluations.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs consider relevant Ongoing Professional Practice Evaluation data in reprivileging recommendations.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board uses professional practice evaluation results to recommend privileges for licensed independent practitioners.

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct environment of care inspections in patient care areas at the required frequency.

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures Automated External Defibrillator cabinets containing naloxone have alarms set in the “on” position, contain tamper-evident seals, display laminated “N” signs, and include naloxone inspection logs and administration reference cards.

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff check inventory in clean storerooms and remove expired supplies in the Emergency Department and medical/surgical inpatient unit.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Environmental Management Service maintains clean floors in the Dialysis Unit and medical/surgical inpatient unit clean storage and supply rooms.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff maintain safe and functional environments in the Dialysis Unit and medical/surgical inpatient unit.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff keep furnishings safe and in good repair in the intensive care and medical/surgical inpatient units.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff repair damaged walls in the Dental Clinic and Emergency Department.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff replace stained ceiling tiles in the Emergency Department and Primary Care Red Team.

The Medical Center Director determines any additional reasons for noncompliance and ensures staff post signage where recording equipment is used in the intensive care and medical/surgical inpatient units, Dental Clinic, and Primary Care Red Team indicating the areas are subject to photography, digital imaging, video, or audio recording.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers assess whether patients’ most recent suicide attempt was their most lethal when completing the Comprehensive Suicide Risk Evaluation.