All Reports

The Chief of Staff ensures service chiefs incorporate service-specific criteria in licensed independent practitioners’ Ongoing Professional Practice Evaluations.

The Chief of Staff ensures service chiefs regularly monitor licensed independent practitioners’ performance through Ongoing Professional Practice Evaluations.

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

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

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 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 Chief of Staff 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 Executive Director ensures Supply Chain Management, Engineering, or Facility Management Service staff monitor temperature and humidity in all clean and sterile storage rooms to maintain a stable environment.

The Executive Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to quality management staff.

The Executive Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a positive suicide risk screen in ambulatory care settings.

The Director ensures staff keep all areas clean and safe.

The Director ensures staff keep the medical center well maintained.

The Chief of Pharmacy Services limits medication access to approved staff members.

The Director ensures staff store sterile supplies in temperature- and humidity-controlled storage rooms.

The Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a positive suicide risk screen.

The Director ensures providers notify the suicide prevention team of patients who report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.

The Medical Center Director ensures staff complete root cause analyses for all patient safety events assigned an actual or potential safety assessment code score of 3.

The Veterans Integrated Service Network Director ensures external practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations for practitioners in “two-deep” services or specialties.

The Medical Center Director ensures the Safety and Occupational Health Specialist or designee tracks environment of care inspection deficiencies until they are resolved.

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

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

The Oklahoma City VA Health Care System Director, in conjunction with Behavioral Health Service leaders, reviews the community care consult management and appointment scheduling processes, identifies deficiencies, 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 Chief of Staff ensures service chiefs monitor licensed independent practitioners’ performance by conducting Ongoing Professional Practice Evaluations on a regular basis.

The Medical Center Director ensures the Safety and Occupational Health Specialist or designee schedules and ensures staff complete and document environment of care inspections at the required frequency.

The Medical Center Director ensures staff monitor and document VA police response times to panic alarm testing in the Acute Inpatient Mental Health Unit at least quarterly.

The Medical Center Director ensures the Suicide Prevention Coordinator conducts a minimum of five outreach activities each month.

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

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

The Chief of Staff ensures service chiefs include service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Associate Director ensures managers maintain a safe and clean environment throughout the medical center.

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

The Chief of Staff ensures providers complete a Comprehensive Suicide Risk Evaluation following a positive suicide risk screen.

The Chief of Staff ensures clinical staff notify the suicide prevention team if patients report suicidal or other self-directed violent behaviors that occurred in the 12 months preceding the Comprehensive Suicide Risk Evaluation.

The Chief of Staff ensures leaders appoint one full-time suicide prevention coordinator to each community-based outpatient clinic that serves at least 10,000 unique veterans annually.

The Chief of Staff ensures the Suicide Prevention Program Manager reports suicide-related events monthly to mental health leaders and quality management staff.

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 Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff document veterans’ care coordination needs within the Community Care Coordination Plan note for consults assigned a level of care coordination above basic.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff act on consults no later than two business days after receipt and document accordingly.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff schedule community care appointments in a timely manner.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff make three attempts to retrieve medical documentation from non-VA providers.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures patients in the home dialysis program receive initial and annual home visits.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff implement and sustain processes to monitor the delivery of non-VA home dialysis.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures each Veterans Integrated Service Network establishes a dialysis council.

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.