All Reports

The VA Fayetteville Coastal Healthcare System Director confirms full implementation of the VA Community Care Oversight and Consult Management Council.

The Under Secretary for Health reviews practices and procedures for managing consults to identify and prioritize appointment scheduling for patients with serious health conditions (high‑priority consults), such as cancer, and provide direction to the field on the process to use to make this determination.

The VA Fayetteville Coastal Healthcare System Director directs the development and implementation of community care service standard operating procedures to address identification and management of high-priority consults, timeliness of consult processing, and care coordination that aligns with direction provided by Veterans Health Administration’s Integrated Veterans Care program.

The VA Fayetteville Coastal Healthcare System Director ensures staff are trained in all newly developed community care standard operating procedures and that adherence to policy and practice is monitored.

The VA Fayetteville Coastal Healthcare System Director confirms completion of a review of quality management processes to ensure quality management staff, when reviewing patient safety events, consider potential system issues and, if present, recommend they be addressed using other quality management reviews.

The VA Fayetteville Coastal Healthcare System Director ensures local processes are in place, including assigned roles and responsibilities, to manage Office of Inspector General case referrals in compliance with VA Directive 0701, Office of Inspector General Hotline Complaint Referrals.

The VA Fayetteville Coastal Healthcare System Director confirms reasonable efforts to conduct an institutional disclosure with the patient regarding circumstances that led to the delay in the diagnosis of and treatment for lung cancer are made and, if a disclosure is completed, that it is documented in the electronic health record.

The Under Secretary for Health assesses the electronic health record reviews completed by the system in response to the community care backlog to determine if a more comprehensive review is warranted with appropriate disclosure to patients placed at risk or harmed as a result of a delay in action on their community care consult, and takes action accordingly.

District leaders and the Prince George’s County Vet Center Director collaborate with the supporting VA medical facility to determine reasons for noncompliance with staff participation in the mental health executive council, take action as indicated, and monitor compliance.

District leaders and the Prince George’s County, Fayetteville, and Chesapeake Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented to complete consultation requirements, and monitor compliance.

District leaders and the Prince George’s County and Fayetteville Vet Center Directors determine reasons for noncompliance with employees completing select training in the required time frame, ensure completion, and monitor compliance.

District leaders and the Prince George’s County, Fayetteville, and Chesapeake Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.

District leaders and the Prince George’s County and Chesapeake Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

District leaders and the Prince George’s County Vet Center Director determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.

District leaders and the Fayetteville and Chesapeake Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

District leaders and the Fayetteville Vet Center Director determine reasons for noncompliance with annual automated external defibrillator servicing by VA medical center biomedical engineering, ensure completion, and monitor compliance.

District leaders and the Chesapeake Vet Center Director determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.

District leaders and the Lancaster Vet Center Director determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented to complete consultation requirements, and monitor compliance.

District leaders and the White Oak Vet Center Director determine reasons for noncompliance with employees completing select training in the required time frame, ensure completion, and monitor compliance.

District leaders and the Dubois, Lancaster, and White Oak Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.

District leaders and the Buffalo Vet Center Director collaborate with the supporting VA medical facility to determine reasons for noncompliance with staff participation in the mental health executive council, take action as indicated, and monitor compliance.

District leaders and the Buffalo, Nassau, and Syracuse Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented to complete consultation requirements, and monitor compliance.

District leaders and the Buffalo, Nassau, and Syracuse Vet Center Directors determine reasons for noncompliance with employees completing select training in the required time frame, ensure completion, and monitor compliance.

District leaders and the Buffalo and Nassau Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.

District leaders and the Syracuse Vet Center Director determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

District leaders and the Syracuse Vet Center Director determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.

District leaders and the Syracuse Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

District leaders and the Syracuse Vet Center Director determine reasons for noncompliance with annual automated external defibrillator servicing by VA medical center biomedical engineering, ensure completion, and monitor compliance.

District leaders and the Nassau and Syracuse Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.

District leaders determine reasons why there are discrepancies in the vet center address on VA and public-facing websites and ensure all websites include correct location information.

District leaders and the New Haven Vet Center Directors collaborate with the supporting VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.

District leaders and the New Haven, Sanford, and Providence Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented to complete consultation requirements, and monitor compliance.

District leaders and the Sanford Vet Center Director determine reasons for noncompliance with completing monthly reviews of 10 percent of active client records for each counselor’s caseload, ensure completion and monitor compliance.

District leaders and the New Haven, Sanford, and Providence Vet Center Directors determine reasons for noncompliance with employees completing select training in the required time frame, ensure completion, and monitor compliance.

District leaders and the New Haven, Sanford, and Providence Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.

District leaders and the New Haven and Providence Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

District leaders and the New Haven Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

District leaders and the Sanford Vet Center Director determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.

The Executive Medical Center Director ensures clinical staff can open all doors to shared bathrooms.

The Executive Medical Center Director ensures staff keep exterior doors closed to minimize risk to wandering patients.

The Executive Medical Center Director ensures staff store clean and dirty equipment and supplies separately.

The Executive Medical Center Director ensures each service has workflows to communicate test results.

Facility leaders ensure the community living center’s dementia unit shower room is clean and free from hazards, and that leaders conduct a risk assessment to determine the need for other safety measures.

The Medical Center Director ensures facility staff conduct a privacy assessment and take actions to protect patient information in the Emergency Department.

Facility leaders ensure all eyewash stations are clean and function properly.

The Medical Center Director ensures the facility has a written policy for communication of test results.

The Chief of Staff and Associate Director of Patient Care Services ensure leaders in each service develop written service-level workflows that outline the process for staff to communicate test results to providers and patients.

The Veterans Integrated Service Network Director ensures executive leaders implement a process to monitor actions related to Veterans Health Administration policy changes.

The Medical Center Director ensures the Chief of Staff and Associate Director of Patient Care Services review performance metrics for test result communications and take action for identified deficiencies.

The Medical Center Director ensures executive leaders attend Quality and Patient Safety Council meetings.

Executive leaders ensure staff properly store endoscopes.

The Medical Center Director ensures each service develops a workflow for the communication of test results.

The Medical Center Director ensures quality management staff report deficiencies identified from the External Peer Review Program to executive leaders, and staff take corrective actions as needed.

The Facility Director ensures the Mental Health Executive Council operates in accordance with Veterans Health Administration requirements.

The Chief of Mental Health ensures compliance with Veterans Health Administration requirements for a full-time local recovery coordinator.

The Chief of Mental Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekdays and weekends on the inpatient mental health unit.

The Facility Director considers consulting with the Office of Mental Health to clarify guidelines for design elements such as artwork on the inpatient unit.

The Facility Director considers alternatives to outdoor access for the inpatient unit, such as those identified in VA’s Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.

The Facility Director develops and implements written processes to monitor and track compliance with state laws for involuntary hospitalization and consults with the Office of General Counsel to ensure processes are consistent with applicable laws.

The Chief of Staff ensures documentation of informed consent discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications.

The Chief of Staff ensures veterans’ discharge instructions are written in easy-to-understand language and include the follow-up mental health appointment location, the purpose of each medication, and how the medication is supposed to be taken.

The Facility Director ensures the Interdisciplinary Safety Inspection Team adheres to Veterans Health Administration requirements, including recording membership and attendance for Mental Health Environment of Care Checklist inspections.

The Veterans Integrated Service Network Director implements processes to ensure the Veterans Integrated Service Network Mental Health Environment of Care Checklist Oversight Team provides facility guidance consistent with Veterans Health Administration requirements.

The Facility Director implements processes to ensure Interdisciplinary Safety Inspection Team staff accurately identify and document safety hazards within the Patient Safety Assessment Tool.

Review and update VHA Directive 1660.07, “Medical Sharing/Affiliate National Program Office,” to delegate all required program office responsibilities for the community-based outpatient clinic contracts throughout the program’s life cycle to an appropriate headquarters-level office or collaboration of offices, as defined in VHA Directive 1217, “VHA Operating Units” and VA’s Acquisition Lifecycle Framework.

Develop and implement procedures for a headquarters-level office to monitor overall compliance with contract requirements and use the results to reassess program policies or contract requirements.

Develop a formal feedback process, such as a program life cycle review process, for contracting officers and contracting officer representatives, medical facilities, and contractors who work on community-based outpatient clinic contracts to provide lessons learned, issues encountered, and other feedback about establishing new clinics and the performance at the clinics.

Conduct an assessment of contractor compliance with all active community-based outpatient clinic contracts, then evaluate whether the community-based outpatient clinic contract performance metrics are measurable, reasonable, and attainable.

Coordinate with the Office of General Counsel to determine whether creating a separate contract line item from the operational costs for contracted community-based outpatient clinics to pay start-up costs, including construction costs, would assist in the administration of these contracts and increase competition among contractors; then update the community-based outpatient clinic performance work statement template to reflect any change made as a result of this consideration.

Assess how medical centers create and maintain the billable roster for community-based outpatient clinic contracts; based on the results, develop and implement efficient, accurate, and consistent procedures for developing and maintaining the billable rosters.

Coordinate with the VA medical centers that have VA-contracted community-based outpatient clinics to conduct a risk assessment to evaluate the responsibilities, time requirements, and qualifications of community-based outpatient clinic contracting officer representatives; then publish clear guidance or recommendations for facilities to make sure they have appropriately experienced, trained, and certified staff to oversee the performance of community-based outpatient clinic contracts.

Assess the certification levels of the CORs assigned to all CBOC contracts and make recommendations to the medical centers for assigning appropriately experienced CORs or to provide any additional training or assistance to existing CORs, if necessary.

Develop and implement procedures to require VA medical centers and contracting offices to verify that the Office of Information Technology can meet start-up requirements for new community-based outpatient clinic locations as part of the contract review process.

Review and evaluate how contracting offices rated community-based outpatient clinic contractors in the Contractor Performance Appraisal Reporting System, and if necessary, develop and disseminate additional guidance or training to contracting offices to help them appropriately rate community-based outpatient clinic contractors in accordance with the performance metrics and the broad categories in the Contractor Performance Appraisal Reporting System.

Determine whether positive and negative performance incentives should be used for community-based outpatient clinic contracts to motivate the contractors to provide high-quality health care, in accordance with FAR 37.6, FAR 16.202, and FAR 16.402-2.

a. If performance incentives are appropriate for community-based outpatient clinic contracts, ensure the Medical Sharing/Affiliate Office coordinates with the Office of General Counsel to develop and implement measurable, reasonable, and defensible positive and negative performance incentives.

b. If performance incentives are not appropriate for community-based outpatient clinic contracts, ensure the Medical Sharing/Affiliate Office and each network contracting office documents in the contract files the reasons why performance incentives are not used to the maximum extent practicable, in accordance with FAR 16.402-2 and FAR 37.6.

Develop and implement procedures to identify, evaluate, and incorporate commercial practices and contract types into the community-based outpatient clinic contract requirements templates before publishing updated versions, in accordance with 38 U.S.C. § 8153 and FAR part 10; the procedures should evaluate whether the contract payment structure for community-based outpatient clinic contracts is consistent with current commercial practices.

The Richard L. Roudebush VA Medical Center Director establishes a process to ensure that changes impacting the availability of clinical services to patients are clearly communicated to all relevant staff members.

The Richard L. Roudebush VA Medical Center Director ensures that residents, fellows, and clinical service leaders understand and follow the requirement to document complete and pertinent information, including assessments and recommendations, in patients’ electronic health records.

The Richard L. Roudebush VA Medical Center Director educates providers on the requirements related to completing a clinical disclosure when an adverse event occurs, such as a delay in care.

The Richard L. Roudebush VA Medical Center Director ensures the episode of care related to the patient’s transfer is reviewed to determine whether an institutional disclosure is needed in accordance with Veterans Health Administration requirements, and takes action as warranted.

The Richard L. Roudebush VA Medical Center Director monitors to ensure that Joint Patient Safety Reporting system reports are included or rejected in accordance with Veterans Health Administration guidance.

The Richard L. Roudebush VA Medical Center Director ensures a comprehensive review of the patient’s care and transfer is completed to identify factors that contributed to the patient’s unnecessary transfer and takes action as warranted.

The Facility Director ensures the Mental Health Executive Council includes veteran representation.

The Associate Chief of Staff, Mental Health ensures the development and implementation of written processes for staff training, education, and recovery-oriented services.

The Associate Chief of Staff, Mental Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit.

The Facility Director develops and implements written processes to monitor and track compliance with state involuntary commitment requirements.

The Chief of Staff ensures discharge instructions for veterans include appointment locations in easy-to-understand language.

The Facility Director directs staff to comply with VA S.A.V.E. training requirements and monitors for compliance.

The Facility Director directs inpatient unit staff, volunteers, and Interdisciplinary Safety Inspection Team members to comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.

Facility leaders direct staff to conduct a risk assessment on liquid nitrogen storage, to include the small devices stored in examination rooms, and implement changes if needed.

Facility leaders determine appropriate supply storage locations and, for any supplies stored outside of the defined locations, implement a process to ensure staff identify and remove expired supplies.

Facility leaders ensure staff label opened multidose medications with expiration dates.

Facility leaders ensure staff store clean and dirty items separately.

The Director ensures staff implement processes to prevent repeat environment of care findings.

The OIG recommends facility leaders ensure the facility has a policy for the communication of test results and staff develop service-level workflows that align with VHA requirements.

Veterans Integrated Service Network 19 leaders assess the staffing needs for the facility’s radiology service and provide additional resources to ensure services are readily available to patients.

Veterans Integrated Service Network 19 leaders evaluate the reasons for delays in uploading images and reporting test results and assist the facility’s community care leaders to mitigate future delays.

Executive leaders monitor root cause analysis improvement actions through completion, monitor outcome measures, and ensure staff implement processes to sustain the improvements.

Facility leaders attain appropriate primary care staffing and manageable panel sizes to ensure patients have timely access to high-quality care.

The Oklahoma City VA Health Care System Director, with Pathology and Laboratory Medicine Service leaders, conducts a comprehensive review of the quality of care for the four patients identified in this report, including determinations of cytopathology processing delays and assessment of patient harm, and takes action as warranted.

The Oklahoma City VA Health Care System Director ensures that routine non-gynecological turnaround time corrective actions are documented and monitored for effectiveness, as required by the Veterans Health Administration.

The Oklahoma City VA Health Care System Director conducts a comprehensive review of the quality of care provided by the Chief of Pathology and Laboratory Medicine Service, identifies deficiencies, and takes action as warranted. 

The Oklahoma City VA Health Care System Director reviews the Pathology and Laboratory Medicine Service event reporting requirements for variance events and ensures completion according to facility policy and Veterans Health Administration requirements.

The Oklahoma City VA Health Care System Director, in conjunction with the National Center for Patient Safety, evaluates patient safety event reporting processes within the Pathology and Laboratory Medicine Service, and ensures completion according to Veterans Health Administration requirements.