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.

Ensure medical facilities establish and implement clear written Homeless Screening Clinical Reminder policies that define the roles and responsibilities of staff involved in the referral, follow-up, and monitoring processes.

Ensure medical facility staff involved in the Homeless Screening Clinical Reminder process are aware of and trained on written local policies and procedures for making referrals, conducting follow-up, and monitoring.

Develop and implement a review process to determine whether medical facility staff followed local Homeless Screening Clinical Reminder policies whenever a veteran does not receive a follow-up encounter within 30 days of a positive screening and correct any identified deficiencies.

Ensure all medical facilities have a reliable report that accurately lists veterans who screened positive and accepted referrals as well as the status of follow-up actions.

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 San Francisco Healthcare System Director confirms the Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub sleep medicine licensed independent practitioners are privileged in accordance with policy and monitors for compliance.

The Sierra Pacific Veterans Integrated Service Network Director ensures Sierra Pacific Veterans Integrated Service Network leaders and San Francisco Healthcare System leaders are educated on Veterans Health Administration policies regarding actions required following licensed independent practitioners’ lapse in privileges.

The Sierra Pacific Veterans Integrated Service Network Director confirms the San Francisco Healthcare System and the Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub leaders complete a review of clinical care rendered by physicians with lapsed privileges as required by the Veterans Health Administration directive.

The Under Secretary for Health ensures the Veterans Health Administration National Program Director, Sleep Medicine and the National Sleep Medicine Field Advisory Board review sleep medicine privileges and provide national guidance for sleep medicine physicians who seek other specialty privileges.

The San Francisco Healthcare System Director ensures that the Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub director addresses sleep medicine physicians’ concern of potential for disruptions in sleep medicine services without dual privileges and notifies sites receiving Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub services if sleep medicine privilege changes will disrupt services.

Identify all veterans using dual entitlement on VA-guaranteed joint home loans who were charged funding fees and received a retroactive disability rating that precedes their loan closing date since July 2019 when the veteran refund eligibility list was implemented, and issue required refunds.

Update systems to ensure eligible veterans using dual entitlement on joint VA-guaranteed home loans are identified for funding fee refunds and ensure that any system updates are tested to demonstrate that the entire population of eligible veterans is included.

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 Under Secretary for Health considers specific VHA guidance related to the recognition of personally owned insulin pumps as a lethal means for patients with suicidal ideation and at risk for suicide in emergency departments and inpatient units to mitigate risk and improve patient safety.

The Associate Director ensures staff make feminine hygiene products available in public women’s and unisex restrooms.

The Medical Center Director ensures staff implement processes to secure medications from unauthorized access.

Biomedical staff indicate inspection dates on all equipment.

The Executive Director ensures staff address environment of care deficiencies within 14 days or have an action plan, as required.

The Executive Director ensures staff perform preventive maintenance on medical equipment in accordance with manufacturers’ recommendations.

The Executive Director ensures staff evaluate the best place to store cleaning supplies, staff store them there, and leaders monitor compliance.

The Executive Director ensures staff remove expired medical supplies and patient food items from patient care areas.

The Executive Director ensures doors in patient care areas have signs to indicate what is stored inside.

Facility leaders ensure staff perform preventive maintenance in accordance with manufacturers’ guidelines and clearly define staff responsibilities.

Executive leaders continue to recruit a permanent chief of biomedical engineering and implement processes to prevent repeat environment of care findings.

The VA Boston Healthcare System Director assesses the timeliness of appointment setting for VA direct and community care referrals and ensures facility staff establish appointments within required time frames.

The VA Boston Healthcare System Director reviews consult management practices and ensures the proper use of consults for VA direct care referrals.

The VA Boston Healthcare System Director reviews appointment wait times and acts on identified opportunities for improvement.

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.