All Reports

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.

The Medical Center Director ensures leaders identify and evaluate sentinel events and conduct and document institutional disclosures when criteria are met.

The Medical Center 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 Chief of Staff ensures service chiefs recommend reprivileging for licensed independent practitioners based, in part, on Ongoing Professional Practice Evaluation data.

The Chief of Staff ensures staff report licensed independent practitioners’ Focused Professional Practice Evaluation results to the Clinical Executive Board.

The Veterans Integrated Service Network Chief Medical Officer provides effective oversight of credentialing and privileging processes at the healthcare system.

The Medical Center Director ensures the comprehensive environment of care coordinator schedules environment of care inspections at the required frequency and verifies staff complete and document them.

The Medical Center Director ensures staff document police response times to panic alarm testing in the Inpatient Mental Health Unit.

The Medical Center Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on Inpatient Mental Health Unit sleeping room doors.

The Medical Center Director ensures staff maintain a safe environment in the Inpatient Mental Health Unit.

The Medical Center Director ensures staff post hazard warning signs on all access doors where potentially infectious materials are located.

The 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 the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.

The Medical Center Director ensures staff identify sentinel events and take appropriate action when home oxygen fires occur.

The Veterans Integrated Service Network Director ensures network staff track and monitor home oxygen vendor completion of root cause analyses when sentinel events occur.

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

The Chief of Staff ensures service chiefs recommend continued privileges for licensed independent practitioners based, in part, on Ongoing Professional Practice Evaluation activities.

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 ambulatory care settings.

Develop and implement policies and system controls to ensure all programs approved for use by vocational rehabilitation counselors for Veteran Readiness and Employment participants meet the requirements of applicable laws and regulations

Train all appropriate Veteran Readiness and Employment regional office staff on manual requirement to verify the programs are approved for use before selecting participants and to verify facility codes match from authorization through enrollment.

The Chief of Staff ensures service chiefs regularly complete Ongoing Professional Practice Evaluations for each licensed independent practitioner.

The Chief of Staff ensures the Executive Committee of the Medical Staff reviews Ongoing Professional Practice Evaluation data and documents its review prior to recommending licensed independent practitioners’ ongoing privileges to the Director.

The Director ensures staff complete environment of care inspections at the required frequency.

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

The Chief of Staff ensures medical staff review and document licensed independent practitioners’ Focused Professional Practice Evaluation results and report them to the Medical Executive Board.

The Chief of Staff ensures service chiefs monitor licensed independent practitioners’ performance by regularly conducting Ongoing Professional Practice Evaluations.

The Medical Center Director ensures staff conduct environment of care inspections in patient care areas at the required frequency.

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 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 calendar day as a patient’s positive suicide risk screen in all ambulatory care settings.

The Deputy Secretary ensures mitigation of the high-risk pharmacy-related patient safety issues identified during the May 2021 National Center for Patient Safety visit.

The Under Secretary for Health evaluates whether the new electronic health record reflects accurate patient medication information per Veterans Health Administration requirements and takes action as indicated.

The Deputy Secretary ensures the resolution of pharmacy-related usability issues identified in this report.

The Deputy Secretary ensures correction of inaccurate medication data transmitted to the Health Data Repository.

The Under Secretary for Health determines the need for and implements a comprehensive strategy to review patients affected by inaccurate medication data transmitted to the Health Data Repository to evaluate whether harm occurred, the need for patients to undergo testing or treatment, and the appropriateness of institutional disclosures.

The Under Secretary for Health ensures patients affected by inaccurate medication data transmitted to the Health Data Repository are notified of the risk of harm per Veterans Health Administration requirements.

The Under Secretary for Health ensures legacy site providers are aware of mitigations needed for patients previously treated at a new electronic health record site and monitors compliance.

The Under Secretary for Health ensures that pharmacist staffing levels are assessed and addressed prior to the implementation of the new electronic health record at additional VA sites

The Under Secretary for Health evaluates the underlying technical and functional issues resulting in workarounds and educational materials needed to perform pharmacy-related operations within the new electronic health record and takes action as indicated.

The Deputy Secretary establishes ongoing monitors to ensure that scheduling procedures in the new electronic health record are functioning in accordance with Veterans Health Administration requirements.

The Under Secretary for Health evaluates minimum scheduling effort requirements for mental health appointments and takes action to ensure the implementation of standardized policy and procedures in the best interest of patient care.

The VA Central Ohio Healthcare System Medical Center Director conducts a full review of the care of the patient provided by the nurse practitioner and psychologist 1, and the supervisory psychologist’s oversight, consults with Human Resources and General Counsel Offices, and takes actions as warranted.

The VA Central Ohio Healthcare System Medical Center Director ensures compliance with the Caring Communication Program including the initiation and cessation of caring communications as required.

The Under Secretary for Health considers establishing written guidance related to documentation, leaders’ review, follow-up actions, and tracking of Lessons Learned in root cause analyses.

The Veterans Integrated Service Network Director ensures that patient advocacy staff within Veterans Integrated Service Network 12 are educated on the need to consult with patient safety staff when complaints involve patient safety concerns.

The Edward Hines, Jr. VA Hospital Director ensures a review is completed of the missed opportunities referenced in this report related to refitting and reeducating patients on VA-issued shoes, determines the need to create a related standard operating procedure or facility policy, and takes action as necessary.