All Reports

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 Carl Vinson VA Medical Center Director ensures that the Sterile Processing Services chief conducts comprehensive staff competency assessments for the reprocessing of reusable medical equipment, and monitors for compliance.

The Carl Vinson VA Medical Center Director ensures that the CensiTrac Instrument Tracking System is fully implemented, and that training is provided to the CensiTrac coordinator and Sterile Processing Services staff, and monitors for compliance.

The Carl Vinson VA Medical Center Director evaluates and ensures that Sterile Processing Services maintains a safe and clean environment in all areas where decontamination, sterilization, or clean and sterile storage of reusable medical equipment are performed, and monitors for compliance.

The Carl Vinson VA Medical Center Director develops an action plan for remediation of the location and use of the training room adjacent to Sterile Processing Services’ clean and sterile storage area, and monitors for compliance.

The Carl Vinson VA Medical Center Director ensures that clinic areas, including radiology, have or share a designated soiled utility room as required by Veterans Health Administration policy, and monitors for compliance.

The Carl Vinson VA Medical Center Director ensures that Sterile Processing Service standard operating procedures for reusable medical equipment are developed, updated consistent with manufacturer’s instructions for use, disseminated, and available at the point of use, and monitors for compliance.

The Veterans Integrated Service Network Director reviews the facility’s Sterile Processing Service water management program and takes action as necessary to ensure compliance with Veterans Health Administration guidance, and monitors for compliance.

The Carl Vinson VA Medical Center Director ensures that the facility Water Working Group submits critical water system test results to the Veterans Integrated Service Network Sterile Processing Services Management Board, as required, and monitors for compliance.

The Veterans Integrated Service Network Director ensures all critical water system test results are reviewed by the Veterans Integrated Service Network Sterile Processing Services Management Board, corrective action is taken when appropriate, and all corrective actions are reported to the National Program Office for Sterile Processing, and monitors for compliance.

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 Director ensures staff complete individual root cause analyses for all adverse patient safety events with an actual or potential safety assessment code score of 3.

The Chief of Staff ensures service chiefs maintain sufficient data for licensed independent practitioners’ Ongoing Professional Practice Evaluations.

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

The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation following a patient’s 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 Associate Director ensures staff keep areas used by patients clean and orderly.

The Associate Director ensures staff store clean and dirty equipment and supplies separately.

The Associate Director ensures staff place all examination tables with the foot facing away from the door.

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

Conduct a review of the convalescence claims for hip and knee replacements and resurfacing completed from February 7, 2021, through August 31, 2022, and take appropriate actions to correct convalescence periods and ensure monetary benefits are accurate.

Implement a plan to assist employees with determining the effective date, incorporating the initial month under 38 C.F.R. § 4.30, and calculating the duration of convalescence.

Develop implementation procedures to include monitoring the accuracy of claims processing when the related rating schedule has been revised.

Supplement training on the rating schedule updates to include how to apply the changes to help ensure comprehension.

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

The North Las Vegas VA Medical Center Director reviews the community care coordination program, identifies deficiencies, and takes actions as warranted to ensure compliance with the Veterans Health Administration Field Guidebook, including training and completion of all care coordination responsibilities for patients discharged from a community hospital stay paid for by the VA.

The North Las Vegas VA Medical Center Director, in conjunction with the Primary Care Service chief, reviews the primary care processes, identifies deficiencies, and ensures compliance with Veterans Health Administration requirements, including response time to patients’ scheduling requests and availability of same-day access for face-to-face and telephone encounters.

The Sierra Pacific Network Director in conjunction with the Chief Medical Officer continues the review of the complete course of care provided by the Veterans Integrated Service Network physician for the patient, including the delivery of anticoagulants, and ability to access scanned documents in the electronic health record, and takes actions as warranted.

The North Las Vegas VA Medical Center Director, in conjunction with the Behavioral Health Service chief and the Primary Care Service chief, review the suicide prevention training program to ensure compliance with Veterans Health Administration policies, including reporting requirements following a patient’s death by suicide; identifies deficiencies; and takes actions as warranted.

The North Las Vegas VA Medical Center Director, in conjunction with the Behavioral Health Service chief, reviews the suicide prevention coordinators’ compliance with Veterans Health Administration policies, including actions required to complete a behavioral health autopsy and family interview tool contact form following a patient’s death by suicide; identifies deficiencies; and takes actions as warranted.

Ensure that healthcare system finance office staff are made aware of all VA financial policy requirements in the review and management of inactive open obligations and deobligate any identified excess funds.

Ensure cardholders comply with VA financial policy record retention requirements.

Establish controls to confirm approving officials and purchase cardholders review purchases for VA policy compliance and ensure contracting is used when it is in the best interest of the government.

Establish local processes and procedures to ensure the routine scanning of inventory items, as well as monitoring of all inventory data, so that performance measures are maintained.

Ensure supply chain managers implement a plan to train staff to promote the standardization of supply chain duties and to correct data validity issues within inventory systems.

Ensure the chief of supply chain services conducts and documents quarterly physical inventory memoranda of “A” classified items in accordance with Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.

Ensure the chief supply chain officer reviews the edit access list for the facility item master file, and a process is put in place to document this review, as required in the Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.

Develop a plan to align inventory management practices, such as ABC inventory analysis methodology, with Veterans Health Administration policy.

Establish processes to ensure compliance with the Veterans Health Administration directive to complete the B09 reconciliation process.

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

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete professional practice evaluations.

The Executive Medical Center Director ensures the Comprehensive Environment of Care Coordinator schedules, and staff complete and document, environment of care inspections at the required frequency.

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

The Executive Medical Center Director ensures appropriate personnel install over-the-door alarms for sleeping room doors in the mental health inpatient unit.

The Executive Medical Center Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on sleeping room doors in the mental health inpatient unit.

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

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

The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation on the same calendar day as a positive suicide risk screen, when logistically feasible and clinically appropriate, for all ambulatory care patients.

The Chief of Staff ensures the Suicide Prevention Coordinator conducts, tracks, and reports a minimum of five suicide prevention outreach activities monthly.

Mediate the two offices’ collaboration to develop and publish updates to the personnel security policies and procedures for vetting contractor employees to include appropriate roles and responsibilities; standard contract language to communicate the requirements for vetting contractor employees, including whether a fingerprint check or background investigation is required, that can be used across the department; and a requirement that the VA organization requesting a contract provide the position designation record in the acquisition package submitted to the contracting office.

Perform and document compliance inspections of the procedures for vetting contractor employees and the issuance of VA identification credentials at medical facilities supported by Network Contracting Office 23, including the St. Cloud VA Medical Center.

Update and publish the Veterans Affairs Acquisition Regulation and Veterans Affairs Acquisition Manual to direct the department’s acquisition professionals to the correct guidance for vetting contractor employees, which should include VA’s personnel security and suitability program policy.

Update and publish or rescind Acquisition Policy Flash 16-13, “Use of VA Handbook 6500.6, Appendix A, Checklist for Information Security in VA Service Acquisitions,” to ensure VA acquisition professionals understand that VA Handbook 6500.6 is not the only personnel security policy they must comply with.

Update and publish VA Handbook 6500.6, Contract Security, in collaboration with the Office of Acquisition, Logistics, and Construction and the Office of Human Resources and Administration/Operations, Security, and Preparedness, including retitling it to better correspond to its content and removing any personnel security steps that should only be discussed in VA personnel security and suitability program policies.

Review the actions of the officials responsible for planning, awarding, and administering contract 36C26320A0021, which included vetting procedures that did not comply with federal or VA policies, and take administrative action if appropriate.

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 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.