All Reports

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 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 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 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 Central Texas VA Health Care System Director reviews the care provided to the patient by Nurse Practitioner 1 and Nurse Practitioner 2 and takes action as warranted.

The Central Texas VA Health Care System Director reviews the care provided by Nurse Practitioner 1 and Nurse Practitioner 2 as licensed independent practitioners to other urology patients, and takes action as warranted.

The Central Texas VA Health Care System Director reviews the privileging and professional practice evaluation processes and performance indicators for nurse practitioners granted full practice authority in specialty care clinics to ensure compliance with current Veterans Health Administration policy and quality of care.

The Central Texas VA Health Care System Director ensures that facility leaders communicate expectations related to low-dose computed tomography scans for lung cancer screening to facility primary care providers.

Develop and implement a strategy with milestones for identifying all VA websites, confirm their inclusion in VA’s Web Registry as the current system designated by policy, and certify the accuracy of entries annually or as changes occur.

Establish a mechanism for web communication offices across VA to enforce the implementation of VA Handbook 6102 related to Section 508 compliance.

Coordinate with VA under secretaries and other assistant secretaries to ensure system owners are educated on VA Directive 6221 and its accompanying handbook requirements to request accessibility audits.

Institute a mechanism to ensure information technology system accessibility designations are accurate in the VA Systems Inventory.

Update, recertify, and republish VA Directives 6221 (accessible information and communications technology) and 6404 (systems inventory).

Update, recertify, and publish VA Directive 6515 (use of web-based collaboration technologies).

The Lt. Col. Luke Weathers, Jr. VA Medical Center Director ensures Nursing Service staff comply with the cardiac telemetry monitoring policy.

The Lt. Col. Luke Weathers, Jr. VA Medical Center Director ensures the medical floor charge nurses create nursing assignments and communicate this information to the telemetry technician and monitors for compliance.

The Lt. Col. Luke Weathers, Jr. VA Medical Center Director ensures that Intensive Care Unit Service physicians document and complete written responses to critical care consults as required and monitors for compliance.

The Lt. Col. Luke Weathers, Jr. VA Medical Center Director ensures that the Quality Management and Performance Improvement Service conduct administrative reviews and root cause analyses in accordance with Veterans Affairs and Veterans Health Administration policy and monitors for compliance.

The Lt. Col. Luke Weathers, Jr. VA Medical Center Director consider completion of another root cause analysis to ensure additional system vulnerabilities that may have contributed to this patient event are identified and action plans completed, as applicable, to prevent reoccurrence of similar patient events.

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 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.

Direct the Office of Financial Management to continue to develop a system for digitally capturing, analyzing, and monitoring public questionnaires to identify inauthentic or potentially fraudulent questionnaires and work with the Compensation Service to develop policies for reviewing and remediating any such public questionnaires identified.

Have the Medical Disability Examination Office update the examiner certification and signature section found in public questionnaires to include that the form is being completed under the penalty of perjury and to ask examiners to list any organizations that requested they complete the examinations on the claimant’s behalf.

Instruct the Compensation Service to provide claims processors guidance in the procedures manual on how to identify a potentially fraudulent public questionnaire, and provide the steps they should take when they suspect that a public questionnaire may be inauthentic or potentially fraudulent.

Require the Compensation Service to inform claims processors as part of the public questionnaire review process that they have a duty to review and weigh all the evidence of record, including public questionnaires, and that they have the responsibility to assign low or no probative value if they have reason to suspect that the public questionnaire is inauthentic or potentially fraudulent.

Direct the Veterans Benefits Administration to develop and provide training on authentication and fraud, including training related to public questionnaires, to provide claims processors with the knowledge to identify inauthentic or potentially fraudulent public questionnaires, and include what steps claims processors should take when they make that determination.

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 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.