All Reports

The Phoenix VA Health Care System Director ensures that providers are educated on conducting clinical disclosures and documenting the discussion in the patient’s electronic health record when harm is determined to be more than minor.

The Phoenix VA Health Care System Director evaluates quality management practices that impede the timeliness of institutional disclosures, and ensures the current practices are in alignment with Veterans Health Administration policy, and takes action as warranted.

The Phoenix VA Health Care System Director confirms that the Peer Review Committee record formal discussions in meeting minutes, including discussion specific to changes in rating levels in accordance with Veterans Health Administration policy, and monitors compliance.

The Phoenix VA Health Care System Director makes certain adverse events or close calls are entered into the Joint Patient Safety Reporting system and the facility patient safety manager completes reviews, assigns a safety assessment code score, and conducts root cause analyses in accordance with Veterans Health Administration policy, and monitors compliance.

The Phoenix VA Health Care System Director evaluates the process for the communication of abnormal test results to patients and ensures that ordering providers or designees provide timely notification to patients in a manner that informs patients of the results in accordance with Veterans Health Administration policy, and monitors compliance.

The Under Secretary for Health evaluates whether low-dose computed tomography lung cancer screenings sent through VA community care have quality assurance practices in place that ensure timely reporting of results to VA facilities consistent with other cancer screenings that are sent through the community care program and takes corrective action to address any identified deficiencies.

The Under Secretary for Health ensures the Veterans Health Administration Office of Integrated Veteran Care reevaluates whether the minimum number of attempts prior to administratively closing consults for community care lung cancer screening with low dose computed tomography scans should continue as an ongoing process, and takes action as warranted.

The Under Secretary for Health reiterates expectations for providers to comply with the Veterans Health Administration directive regarding communication of test results to patients, including required time frames.

The Under Secretary for Health evaluates whether low-dose computed tomography lung cancer screenings sent through VA community care have quality assurance practices in place that ensure follow-up on scan results consistent with other cancer screenings that are sent through the community care program and takes corrective action to address any identified deficiencies.

The Under Secretary for Health facilitates a comprehensive review of the patient cases provided by the Office of Inspector General, assesses these patients for adverse clinical outcomes, and implements action plans as needed.

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges evaluate licensed independent practitioners on an ongoing basis.

The Director determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for applicable sentinel events.

The Chief of Staff determines the reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in Ongoing Professional Practice Evaluations.

The Director evaluates and determines any additional reasons for noncompliance and ensures staff maintain medical supplies that are not contaminated, damaged, expired, or recalled.

The Chief of Staff or Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff post notices in treatment areas with overt recording announcing the area is subject to photography or video recording.

The Director evaluates and determines the reasons for noncompliance and ensures staff create or update safety plans for patients with a positive suicide risk screen who are determined safe to discharge home from the Emergency Department.

The Chief of Staff ensures designated staff complete a 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.

Establish a process to identify and track veterans’ files for those determined to have fire-damaged or destroyed records, such as adding a corporate flash, and update the Adjudication Procedural Manual indicating when veterans service representatives should apply such procedures.

Instruct veterans service representatives on the process for requesting service treatment and military service records for fire-related records, which includes more specific guidance on what information is required for the National Personnel Records Center to locate veterans’ records.

Ensure veterans service representatives are made aware of and follow steps as outlined in the manual for when to send required forms and conduct follow-up contact with veterans.

The Houston VA Medical Center Director ensures that staff conduct and document focused professional practice evaluations for cause as required by the Veterans Health Administration.

The Houston VA Medical Center Director reviews processes for reporting providers to state licensing boards and the national practitioner data bank when a concern for patient safety is identified, and takes action to ensure compliance.

The Houston VA Medical Center Director reviews the processes for conducting root cause analyses to ensure that reports are completed timely and that action plans are measurable, sustainable, and monitored to completion.

The assistant under secretary for health for support should establish certification procedures for Veterans Integrated Service Networks to ensure medical facilities’ healthcare-associated Legionella disease prevention plans for buildings comply with Veterans Health Administration Directive 1061 requirements.

The assistant under secretary for health for support should develop and ensure Veterans Integrated Service Networks perform and document quality control and quality assurance checks of their requirements for oversight and enforcement of the Veterans Health Administration Directive 1061 quarterly Legionella water testing procedures conducted by the facility.

The assistant under secretary for health for operations should monitor Veterans Integrated Service Network officials fulfillment of their oversight responsibilities found in Veterans Health Administration Directive 1061 regarding Legionella water sampling, testing, remediation efforts, and reporting of Legionella water testing data, including the post-remediation test results.

The director of the Office of Healthcare Engineering should consider alternative measures, such as adding dedicated resources, to provide expertise and support for medical facilities experiencing persistent positive Legionella in facility water supply systems after applying the remediation efforts prescribed by Veterans Health Administration Directive 1061.

The director of the Office of Healthcare Engineering should assist the Salem VA medical center with their persistent positive Legionella in the facility water supply system, and, with consideration of the ongoing water supply system renovations, develop an action plan to mitigate remediation challenges.

The director of the Office of Healthcare Engineering should clarify the responsibility section of Veterans Health Administration Directive 1061 to clearly define oversight responsibilities for ensuring required remediation steps are completed when facilities received positive Legionella water test results.

The director of the Office of Healthcare Engineering should revise the Water Safety Management Tool to alert Veterans Integrated Service Network and medical facility oversight officials when quarterly testing data is not posted.

The assistant under secretary for health for operations should take actions to confirm that Veterans Integrated Service Network officials are ensuring front-line staff are routinely notified by responsible medical facility officials when elevated Legionella water sample levels require diagnostic awareness and additional clinical surveillance of veterans to detect Legionnaires’ disease.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs complete Focused Professional Practice Evaluations.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs consistently review Ongoing Professional Practice Evaluation data.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete the Comprehensive Suicide Risk Evaluation following a positive suicide risk screen and include an assessment of whether the current suicidal ideation was the most severe in the last 30 days.

The System Director evaluates and determines any additional reasons for noncompliance and ensures leaders follow their defined governance structure.

The Chief of Staff determines any additional reasons for noncompliance and ensures leaders use service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Chief of Staff determines any additional reasons for noncompliance and ensures service chiefs maintain Ongoing Professional Practice Evaluation data in licensed independent practitioners’ privileging folders.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete professional practice evaluations of licensed independent practitioners.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Executive Committee of the Medical Staff reviews the service chiefs’ recommendations along with clinical competence information when making privileging recommendations for licensed independent practitioners.

The System Director determines any additional reasons for noncompliance and ensures staff maintain a clean and safe environment.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define time frames for Focused Professional Practice Evaluations.

The Director evaluates and determines any additional reasons for noncompliance and ensures clinicians create or update a suicide safety plan for patients determined to be at intermediate, high-acute, or chronic risk-for-suicide and safe to discharge home from the Emergency Department.

The Director evaluates and determines any additional reasons for noncompliance and ensures clinicians follow up within seven days with patients determined to be at intermediate, high-acute, or chronic risk-for-suicide who were discharged home from the Emergency Department.

The Hampton VA Medical Center Director assesses the current use of care coordination agreements between the Patient Aligned Care Team and specialty care services, and determines if there would be benefit in developing agreements where they do not currently exist.

The Hampton VA Medical Center Director, in conjunction with the Radiology Department chief, reviews the Radiology Department standard operating procedures and scheduling processes, identifies deficiencies, and ensures compliance with Veterans Health Administration policies.

The Hampton VA Medical Center Director, in conjunction with the Primary Care Service chief, reviews the Patient Aligned Care Team processes, identifies deficiencies, and ensures compliance with Veterans Health Administration Patient Aligned Care Team requirements, including scheduling huddles, follow-up of Emergency Department patient discharges, and communication with and coordination of specialty care.

The Hampton VA Medical Center Director, in conjunction with the Primary Care Service chief, reviews the Patient Aligned Care Team pain management and referral processes, identifies deficiencies, and takes action as warranted.

The Hampton VA Medical Center Director, in consultation with a subject matter expert from the National Program Office for Oncology, reviews the facility cancer registry program, identifies deficiencies, and ensures compliance with Veterans Health Administration requirements, including the need for a qualified cancer registrar and entry of all cancer cases in the registry.

The Hampton VA Medical Center Director reviews the completed root cause analysis in order to ensure its completeness, and take action if warranted.

The Assistant Under Secretary for Health for Quality and Patient Safety establishes facility patient safety program oversight requirements for patient safety officers to include minimum frequency and volume of oversight activities and expectations for follow-up when patient safety program deficiencies are identified.

The National Center for Patient Safety Executive Director evaluates the National Center for Patient Safety quarterly reports, includes an analysis of patient safety data in the reports, and establishes a mechanism for National Center for Patient Safety, in conjunction with Veteran Integrated Service Networks, to direct interventions to promote improvements when facility patient safety program requirements are not met or if deemed necessary to enhance patient safety programs.

The Under Secretary for Health evaluates barriers to communication between third-party administrators and patient safety officers and takes action as needed to resolve barriers.

The Assistant Under Secretary for Health for Quality and Patient Safety evaluates barriers that limit engagement between Veteran Integrated Service Network and facility directors and patient safety officers and patient safety managers.

The National Center for Patient Safety Executive Director develops a patient safety program staffing configuration for patient safety managers to include facility complexity and patient safety program requirements with recurring reassessment and revision based on requirement changes.

The National Center for Patient Safety Executive Director establishes staffing guidance for Veteran Integrated Service Network patient safety programs to include facility complexity and workload from other assigned responsibilities to ensure prioritization of patient safety officer oversight and support of facility patient safety programs.

The National Center for Patient Safety Executive Director establishes processes to evaluate factors contributing to patient safety managers and patient safety officers’ burnout, including patient safety manager turnover, and implements actions as needed to address burnout.

The National Center for Patient Safety Executive Director evaluates patient safety manager and patient safety officer training and implements standardized formalized training with requirements for newly appointed patient safety managers and newly appointed patient safety officers to include time frames and completion.

The National Center for Patient Safety Executive Director establishes standardized continuing education requirements to meet the training needs for patient safety managers and patient safety officers.

Improve vulnerability management processes to ensure system changes occur within organization timelines.

Develop and approve an authorization to operate for the special-purpose systems.

Include system personnel during the security categorization process to ensure that all necessary information types are considered when determining the security categorization for special-purpose systems.

Implement the appropriate physical security controls to restrict and monitor access to the facility, its server room, communication closets, and generators.

Implement and monitor emergency power and uninterruptible power supplies that support information technology resources.

Validate that appropriate physical and environmental security measures are implemented and functioning as intended.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs document professional practice evaluation results in practitioners’ profiles and report them to the Executive Committee of the Medical Staff Credentialing and Privileging.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures services chiefs base reprivileging recommendations on service-specific Ongoing Professional Practice Evaluation data.

The System Director evaluates and determines any additional reasons for noncompliance and ensures staff document VA Police response times to panic alarm testing in the inpatient mental health unit.

The System Director evaluates and determines any additional reasons for noncompliance and ensures staff keep patient care areas clean and maintain furnishings and equipment in good working order.

The System Director evaluates and determines any additional reasons for noncompliance and ensures staff test over-the-door alarms for inpatient mental health unit sleeping rooms as required.

The System Director evaluates and determines any additional reasons for noncompliance and ensures staff properly store and secure medications.

The System Director evaluates and determines additional reasons for noncompliance and ensures staff conduct timely follow-up for intermediate, high-acute, or chronic risk-for-suicide patients who are discharged home from the Emergency Department.

The assistant secretary for information technology develop a timeline for updating the security and privacy guidance to reflect the latest revisions to the National Institute of Standards and Technology Special Publication 800-53, Security and Privacy Controls for Federal Information Systems and Organizations, and address identified weaknesses with personally identifiable information and supply chain management.

The assistant secretary for information technology eEstablish a mechanism to ensure continuous monitoring of VA Enterprise Cloud systems to include having and testing contingency, incident response, and disaster recovery plans and conducting scanning as required.

The assistant secretary for information and technology continue to improve criteria and processes for submitting claims for recoupment of service credits.

The assistant secretary for information and technology assign roles and responsibilities for submitting claims for service credits and monitoring outcomes.

Implement a more effective vulnerability management program to address security deficiencies identified during the inspection.

Ensure vulnerabilities are remediated within OIT’s established time frames.

Ensure physical access controls are implemented for communication rooms.

Ensure communication rooms with infrastructure equipment have adequate environmental controls.

Test the emergency power bypass during annual uninterruptible power supply testing and document results.

The Director evaluates and determines any additional reasons for noncompliance and ensures staff complete an individual root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

The Chief of Staff determines the reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures service chiefs recommend reprivileging based, in part, on Ongoing Professional Practice Evaluation data.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs report Focused Professional Practice Evaluation results to the Medical Executive Board.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board reviews Ongoing Professional Practice Evaluation results and documents its review when making reprivileging recommendations to the Director.

The Director determines the reasons for noncompliance and ensures staff conduct environment of care inspections at the required frequency.

The Director determines any additional reasons for noncompliance and ensures staff maintain a clean and safe environment.

The Director determines any additional reasons for noncompliance and ensures staff maintain a safe environment in the inpatient mental health unit.

The Associate Director for Patient/Nursing Services determines the reasons for noncompliance and ensures only authorized personnel have access to medication and supply rooms.