All Reports

The Executive Director ensures the Chief of Staff conducts institutional disclosures for applicable sentinel events.

The Chief of Staff ensures service chiefs document Focused Professional Practice Evaluation results in licensed independent practitioners’ profiles.

The VA Loma Linda Healthcare System Director confirms that a mechanism is in place to monitor primary care patient aligned care team staffing and panel sizes at the non-VHA-operated clinics to ensure staff are available to care for enrolled patients.

The VA Loma Linda Healthcare System Director directs a review be done of VA Loma Linda Healthcare System adherence to Veterans Health Administration metrics for the processing and scheduling of community care consults and, if not met, determines the reasons for noncompliance, creates an action plan to address deficiencies, and monitors for compliance.

The VA Loma Linda Healthcare System Director conducts an assessment of the community- based outpatient clinic steering committee to ensure consistent oversight of quality of care and staffing levels for all of the VA Loma Linda Healthcare System’s VA outpatient clinics.

The Chief of Staff ensures service chiefs document professional practice evaluation results in practitioners’ profiles, and the Medical Executive Committee reviews service chiefs’ recommendations along with clinical competence information when making privileging recommendations to the Director.

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

The Director ensures staff regularly test panic alarms in the mental health inpatient unit and document VA police response times.

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

The Director ensures staff maintain a safe environment in the Emergency Department for mental health patients.

The Chief of Staff 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 District Director monitors compliance with leaders’ completion of morbidity and mortality reviews for client deaths by suicide, including timeliness, as required.

The District Director identifies reasons for noncompliance with timely documentation requirements of high-risk client contacts and outcomes in the electronic record and High Risk Suicide Flag SharePoint site, ensures requirements are met, and monitors compliance.

The Readjustment Counseling Service Chief Officer ensures the High Risk Suicide Flag SharePoint site functions as intended and includes accurate data.

The District Director and zone leaders identify reasons for noncompliance, ensure Readjustment Counseling Service policy confidentiality requirements are followed when collaborating care with the support VA medical facility for shared clients at high risk for suicide, and monitor compliance across all zone vet centers.

The District Director identifies reasons for noncompliance with consultation requirements for clients who are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories; ensures consultation requirements are met; and monitors compliance.

The District Director identifies reasons for noncompliance; ensures clinical staff complete safety plans for clients who are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories as required; and monitors compliance across all zone vet centers.

The District Director identifies reasons for noncompliance, ensures clients are provided a copy of their completed safety plan as required, and monitors compliance across all zone vet centers.

District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Lakeland, Naples, and San Juan Vet Center Directors, collaborate with the support VA medical facility clinical liaison to determine the reasons for noncompliance, take action as indicated, and monitor to ensure compliance with staff participation on the mental health executive council.

District leaders and the Lakeland Vet Center Director, determine reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for at-risk clients, take action to ensure requirements are met, and monitor compliance.

District leaders and the Lakeland Vet Center Director determine reasons for noncompliance and ensure assignment of a liaison.

District leaders and the Lakeland Vet Center Director determine reasons for noncompliance and ensure assignment of an external clinical consultant.

District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Naples, and San Juan Vet Center Directors determine reasons for noncompliance, ensure a process is implemented for completing and tracking four hours of external clinical consultation per month, and monitor compliance.

District leaders and the Ft. Lauderdale, Gainesville, and Lakeland Vet Center Directors determine reasons for noncompliance with monthly active counseling records, ensure chart audits are completed as required, and monitor compliance.

District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Lakeland, and San Juan Vet Center Directors determine reasons for noncompliance, develop processes to ensure all staff complete mandatory trainings, and monitor compliance.

District leaders and the Gainesville and Lakeland Vet Center Directors determine reasons for noncompliance and ensure outreach plans are completed.

District leaders and the Ft Lauderdale, Ft. Myers, Naples, and San Juan Vet Center Directors determine reasons for noncompliance and ensure outreach plans include all required strategic components.

District leaders and the Ft. Myers, Naples, and San Juan Vet Center Directors determine reasons for noncompliance, ensure outreach activities are tailored to the cultural demographics of the vet center’s veteran service area, and monitor compliance.

District leaders and the Gainesville Vet Center Director determine reasons for noncompliance, ensure completion of fire and/or safety inspections, and monitor compliance.

District leaders and the Gainesville Vet Center Director determine reasons for noncompliance, ensure the risk and vulnerability assessment is completed by VA police or local law enforcement, and monitor compliance.

District leaders and the Gainesville and Naples Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are serviced annually, and monitor compliance.

District leaders and the Ft. Lauderdale and Naples Vet Center Directors determine reasons for noncompliance, ensure fire extinguishers are inspected monthly, and monitor compliance.

District leaders and the Ft. Myers Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are inspected monthly, and monitor compliance.

District leaders, and the Naples Vet Center Director, determine reasons for noncompliance and ensure evacuation plans are posted in a communal area.

District leaders and the Ft. Lauderdale, Ft. Myers, Lakeland, and Naples Vet Center Directors determine reasons for noncompliance, ensure completion of a current and comprehensive emergency and crisis plan, and monitor compliance.

District leaders and the Marietta, Bay County, and Savannah Vet Center Directors collaborate with the support VA medical facility clinical liaisons to determine the reasons for noncompliance, take action as indicated, and monitor to ensure compliance with staff participation on the mental health executive council.

District leaders and the Marietta and Charleston Vet Center Directors determine reasons for noncompliance, ensure a process is implemented for completing and tracking four hours of external clinical consultation per month, and monitor compliance.

District leaders and the Augusta, Johnson City, Marietta, Charleston, Bay County, and Savannah Vet Center Directors determine reasons for noncompliance, develop processes to ensure all staff complete mandatory trainings, and monitor compliance.

District leaders and the Charleston Vet Center Director determine reasons for noncompliance and ensure outreach plans are completed.

District leaders and the Augusta, Johnson City, Marietta, Bay County, and Savannah Vet Center Directors determine reasons for noncompliance and ensure outreach plans include all required strategic components.

District leaders and the Augusta, Johnson City, and Savanah Vet Center Directors determine reasons for noncompliance, ensure outreach activities are tailored to the cultural demographics of the vet center’s veteran service area, and monitor compliance.

District leaders and the Augusta Vet Center Director determine reasons for noncompliance, ensure the risk and vulnerability assessment is completed by VA police or local law enforcement, and monitor compliance.

District leaders and the Augusta Vet Center Director determine reasons for noncompliance, ensure fire extinguishers are serviced annually and monitor compliance.

District leaders and the Augusta, Johnson City, Charleston, and Bay County Vet Center Directors determine reasons for noncompliance, ensure fire extinguishers are inspected monthly, and monitor compliance.

The District Director and zone leaders, in conjunction with the Augusta Vet Center Director, determine reasons for noncompliance and ensure vet center obtains an automated external defibrillator.

District leaders and the Charleston Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are inspected monthly, and monitors compliance.

District leaders and the Charleston and Bay County Vet Center Directors determine reasons for noncompliance, ensure completion of a current and comprehensive emergency and crisis plan, and monitor compliance.

District leaders and the Charleston Vet Center Director determine reasons for noncompliance, and ensures ancillary staff have a desktop reference sheet to address mental health crisis situations.

The Veterans Integrated Service Network Director ensures the Veterans Integrated Service Network Chief Medical Officer oversees the hospital’s privileging process.

The Hospital Director ensures staff conduct environment of care inspections in non patient care areas at least once per fiscal year.

The Hospital Director ensures the suicide prevention team conducts a minimum of five outreach activities per month.

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

The Hospital 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 Medical Center Director ensures the Suicide Prevention Coordinator conducts at least five outreach activities each month.

The Chief of Staff ensures the Peer Review Committee recommends improvement actions for all peer reviews.

The Director ensures staff conduct environment of care inspections in patient care areas at least twice per fiscal year.

The Associate Director ensures staff maintain all medical equipment in accordance with manufacturers’ recommendations or use an alternative maintenance program that does not reduce the safety of the equipment.

The Chief of Staff ensures medications transported by the pneumatic tube system are only accessible by approved individuals.

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

The Director ensures staff check over-the-door alarms in mental health inpatient units with corridor doors to patient sleeping rooms according to the manufacturer’s guidelines.

The Director ensures all entrances into mental health inpatient units have a sally port.

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

The Medical Center Director ensures staff document VA police response times to panic alarm testing in the Inpatient Psychiatry Unit

The Medical Center Director ensures staff follow the manufacturer’s guidelines for checking over-the-door alarms for patient sleeping rooms in the Inpatient Psychiatry Unit.

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

The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.

The Chief of Staff ensures service chiefs recommend continuation of current privileges based on Ongoing Professional Practice Evaluation activities

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

The Chief of Staff ensures service chiefs recommend continued privileges based on Ongoing Professional Practice Evaluation activities

The Chief of Staff ensures the Executive Committee of the Medical Staff/Credentials Committee recommends continuation of licensed independent practitioners’ privileges based on Ongoing Professional Practice Evaluation results.

The Associate Director ensures staff check inventory in clean and sterile storerooms and remove expired or outdated items.

The Director ensures leaders conduct institutional disclosures for applicable sentinel events.

The Director ensures staff complete a root cause analysis for all events assigned an actual or potential safety assessment code score of 3.

The Associate Director ensures staff keep patient areas clean and free from undue wear.

The Director ensures staff check over-the-door alarms on the mental health inpatient unit according to the manufacturer’s guidelines.

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

The Director ensures leaders conduct institutional disclosures for applicable sentinel events.

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

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

The Associate Director ensures staff keep furnishings and walls in good repair.

The Associate Director ensures staff use solid bottom shelves in storage areas.

The Associate Director ensures staff inspect, test, and maintain medical equipment.

The Associate Director ensures staff document VA police response times for panic alarm testing in the mental health inpatient unit.

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

The Chief of Staff ensures service chiefs report Focused Professional Practice Evaluation results to an executive committee of the medical staff for consideration in privileging recommendations.

The Director ensures staff conduct environment of care inspections in patient care areas as required.

The Director ensures staff test panic alarms in the Inpatient Psychiatry Unit at least quarterly and record testing in a log, including police response times.

The Director ensures staff test over-the-door alarms in the Inpatient Psychiatry Unit per the manufacturer’s recommendations.

The Director ensures staff keep interior spaces in the Inpatient Psychiatry Unit safe and suitable for care.

The 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 Under Secretary for Health reviews the criteria and processes used to identify and exclude healthcare providers removed from VA employment for violation of policy related to safe and appropriate care of veterans, and takes action as warranted.

The Under Secretary for Health reviews previous removals of healthcare providers from VA employment as required by VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 § 108 to determine whether the reason(s) for those removals were for violation of policy related to the safe and appropriate care of veterans, and takes action as warranted.

Holds future third-party administrators accountable for operational readiness and provider network adequacy at each facility by the time the contracts are implemented.

Develops a process to make sure the third-party administrators regularly update their Community Care Network provider lists to reflect accurate provider contact information and annotate providers who are not currently accepting VA patients.

Develops a mechanism for facilities to effectively report, track, and monitor challenges with access to specialty care services; trains all relevant staff on how to use the mechanism; make sure facilities use the mechanism routinely; and then helps facilities resolve access challenges.

Develops and communicates to facilities a standard process to request and document their needs for additional providers.

Evaluates the effectiveness of the third-party administrators’ quarterly and monthly reports for assessing network adequacy and then, if needed, modifies the language in its current contracts and makes changes to the applicable contract language for future Community Care Network contracts.

Develops its own network adequacy performance reports for each facility and communicates the results to the facilities monthly.

Conducts Advanced Medical Cost Management Solution training for community care staff at each facility on evaluating network adequacy through the tool.

Routinely evaluates the third-party administrator’s network adequacy performance reports to ensure the reports are sufficiently reliable and comply with contract requirements, and then holds third-party administrators accountable for resolving identified issues.

The Chief of Staff ensures staff record the Peer Review Committee’s formal discussions related to changes in peer review level assignments in the meeting minutes.

The Chief of Staff ensures the Medical Staff Executive Committee reviews data provided by the Peer Review Committee to determine the need for further action.

The Chief of Staff ensures service chiefs complete Ongoing Professional Practice Evaluations prior to reprivileging to ensure continuous delivery of quality care.

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

The Associate Director ensures the Comprehensive Environment of Care Rounds Coordinator or designee schedules environment of care inspections and staff complete and document them at the required frequency.

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

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

The Medical Center Director ensures staff test over-the-door alarms based on the manufacturer’s recommendations for mental health inpatient unit sleeping rooms.

The Medical Center Director ensures staff check all mental health inpatient unit ceiling tiles semiannually.

The Veterans Integrated Service Network Director ensures the Medical Center Director has sufficient biomedical staff and confirms they inspect and test all medical equipment for scheduled maintenance.

The Veterans Integrated Service Network Director ensures compliance with VHA Directive 1860, Biomedical Engineering Performance Monitoring and Improvement, for oversight structure of the medical center’s biomedical program.

The Medical Center Director ensures designated staff complete the Comprehensive Suicide Risk Evaluation on the same calendar day as a positive suicide risk screen, when clinically appropriate, for all ambulatory care patients.

The Under Secretary for Health ensures Veterans Health Administration prescribers establish a diagnosis based on a complete and documented assessment prior to initiation of a stimulant to treat attention deficit hyperactivity disorder.

The Under Secretary for Health ensures Veterans Health Administration prescribers assess risks and contraindications associated with stimulant prescribing.

The Under Secretary for Health evaluates the prescription drug monitoring program query adherence goal for initial stimulant prescribing and takes action as warranted.

The Under Secretary for Health evaluates the adequacy of the referral processes related to complex mental health disorders, such as attention deficit hyperactivity disorder, and takes action as warranted.

The Under Secretary for Health considers establishing policy and clinical practice guidance related to attention deficit hyperactivity disorder diagnostic assessment and treatment with a stimulant and takes action as warranted.

The Chief of Staff ensures service chiefs define the time frames for Focused Professional Practice Evaluations.

The Chief of Staff ensures service chiefs recommend reprivileging based, in part, on Ongoing Professional Practice Evaluation activities

The Director ensures staff remove corrugated containers from patient care areas.

The Director ensures staff keep storerooms clean and free of visible dust and soiling.

The Director ensures Environmental Management Services staff keep patient care areas clean.

The Associate Director for Patient Care Services ensures staff remove expired commercial products from patient care areas.

The Director ensures staff store clean and dirty equipment separately.

The Director ensures staff maintain walls to allow for thorough cleaning.

The Associate Director ensures staff test over-the-door alarms in the Inpatient Mental Health unit per the manufacturer’s recommendations.

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