All Reports

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

The System Director determines any additional reasons for noncompliance and ensures staff conduct required preventive maintenance on medical equipment.

The Chief of Staff determines the reasons for noncompliance and ensures only authorized staff have access to medications.

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

The Charlie Norwood VA Medical Center Director establishes a process to optimize communication between the Surgery Service and the Spinal Cord Injury Service when providing care to spinal cord injury patients.

The Charles George VA Medical Center Director evaluates processes for mental health consult scheduling, including community care referrals, and ensures patients are offered timely appointments, per Veterans Health Administration policies.

The Charles George VA Medical Center Director confirms outpatient Mental Health staff receive education about Veterans Health Administration and facility policies related to mental health consult processes, including timeliness and community care consults.

The Charles George VA Medical Center Director evaluates the design, staffing, and implementation of the Behavioral Health Interdisciplinary Program to ensure the program supports timely access to mental health care and takes action as appropriate.

The Charles George VA Medical Center Director confers with Mental Health leaders to identify, track, and mitigate barriers to staff retention and takes appropriate action.

The Charles George VA Medical Center Director ensures Mental Health leaders review current communication practices within Mental Health operations, in accordance with Veterans Health Administration High Reliability Organization values and principles and considers the use of VHA resources, such as the National Center for Organization Development.

The Charles George VA Medical Center Director ensures Mental Health leaders educate Mental Health clinic staff on the role of the suicide prevention team in patient care.

The Charles George VA Medical Center Director reviews and evaluates processes for monitoring and managing Veterans Health Administration-required follow-up care for patients with high risk for suicide patient record flags, including scheduling and tracking of required follow-up appointments, and monitoring compliance.

The Health Care System Director determines the reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.

The Health Care System Director evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for all Level 3 peer reviews, and supervisors ensure implementation of those actions.

The Health Care System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager conducts a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee reviews Ongoing Professional Practice Evaluation results and documents privileging decisions in the meeting minutes.

The Associate Director for Patient Care Services/Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures staff check supply rooms for expired supplies and discard them.

The Director evaluates and determines any additional reasons for noncompliance and ensures leaders evaluate sentinel events and conduct institutional disclosures when criteria are met.

The Director determines any additional reasons for noncompliance and ensures the Comprehensive Environment of Care Coordinator or designee schedules and ensures staff complete environment of care inspections in patient care areas at the required frequency and document the inspection results.

The Director evaluates and determines any additional reasons for noncompliance and ensures staff keep patient care areas clean and furnishings and equipment safe and in good repair.

The 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 Executive Chief of Staff ensures peer reviewers identify at least one aspect of care when assigning a Level 2 or 3 to a peer review.

The Executive Chief of Staff ensures the Peer Review Committee recommends improvement actions to reviewed providers.

The Executive Chief of Staff ensures supervisors communicate the Peer Review Committee’s recommendations to providers and ensure they implement improvement actions for all Level 2 and 3 peer reviews.

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

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

The Deputy Medical Center Director ensures the Comprehensive Environment of Care Coordinator or designee monitors environment of care inspection deficiencies until resolution.

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

The Deputy Medical Center Director ensures staff post hazard warning signs in all areas where potentially infectious materials are located.

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

The Executive Chief of Staff ensures suicide prevention coordinators report suicide-related events to mental health leaders and quality management staff at least monthly

The Executive Chief of Staff ensures designated staff complete a 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 Executive Chief of Staff ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.

The West Haven VA Medical Center Director ensures communication with patients, families, and staff throughout emergency operations according to the Veterans Health Administration’s Emergency Management Program Guidebook.

The West Haven VA Medical Center Director confirms that medical, nursing, and respiratory therapy staff have the equipment, education, and training to prepare for emergency oxygen procedures.

The West Haven VA Medical Center Director ensures completion of pre-construction risk assessments.

The West Haven VA Medical Center Director ensures patient safety staff participate in facility Construction Safety Committee meetings and activities.

The West Haven VA Medical Center Director evaluates the need for increased oversight of contracted construction companies during high-risk or potential high-risk situations such as construction around underground utilities.

The West Haven VA Medical Center Director ensures annual drills and training to address utility emergencies are completed.

The West Haven VA Medical Center Director confirms that joint patient safety reports are entered for adverse events and close calls and root cause analyses are chartered for high-risk events or potential high-risk events not related to falls, medications, and missing patients.

The West Haven VA Medical Center Director ensures clinical staff document each event of a patient’s care into the health record.

The West Haven VA Medical Center Director ensures that the patient’s episodes of care are reviewed to determine whether a clinical disclosure is needed in accordance with Veterans Health Administration requirements and takes action accordingly.

The West Haven VA Medical Center Director ensures that staff who are designated as a fact finder for a fact-finding investigation receive the needed training and do not have a conflict of interest.

The West Haven VA Medical Center Director determines whether administrative action should be taken with respect to the conduct and performance of the chief of respiratory care.

The Veterans Integrated Service Network Director reviews the content, accuracy, and intent of the Situation, Background, Assessment, Recommendation document and takes administrative action as warranted.

The Medical Center Director evaluates and determines reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.

The Chief of Staff evaluates and determines reasons for noncompliance and ensures clinicians complete the Comprehensive Suicide Risk Evaluation following a positive suicide risk screen.

Implement consistent data entry, standardized organizational codes, and periodic reviews for HR Smart community care data.

Develop staffing reports that can be searched by service departments to ensure appropriate resources to meet their assigned missions.

Improve usability of the staffing assessment tool by implementing policy to address the inconsistencies with staffing data entry and review the reported data for accuracy.

Assess whether consolidated community care units would more broadly support veterans’ access to community care and help mitigate the impact of staffing shortages, and, if so, develop a project management plan for implementing those units.

Assess the use of monetary and nonmonetary incentives to evaluate whether they are effective in recruiting and retaining administrative staff within community care departments.

The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director evaluates and ensures all Veterans Integrated Service Network 10 facilities comply with Veterans Health Administration requirements regarding resident supervision, specifically related to post-graduate year one on-site direct supervision.

The John D. Dingell VA Medical Center Director reviews the March 2023 National Surgery Office program review as referenced in the Office of the Medical Inspector report and ensures a comprehensive and sustainable response to the recommendations noted in the National Surgery Office memorandum.

The John D. Dingell VA Medical Center Director and facility leaders meet all Veterans Health Administration requirements for National Practitioner Data Bank and State Licensing Board reporting for healthcare providers that meet reporting criteria.

The John D. Dingell VA Medical Center Director ensures the chief of surgery facilitates and provides oversight of morbidity and mortality conferences.

The John D. Dingell VA Medical Center Director ensures that initial level 3 peer review results of Peer Review Committee members’ cases are reassessed by another neutral VA facility Peer Review Committee for final level determination.

The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director ensures the Veterans Integrated Service Network academic affiliations officer maintains awareness of and performs assigned roles and responsibilities per Veterans Health Administration requirements.

The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director ensures the Veterans Integrated Service Network surgical workgroup reviews applicable Veterans Health Administration policies, and documents discussion and action plans to reflect facilities’ compliance with Veterans Health Administration policy and surgical complexity level.

The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director provides continued oversight and structured support to executive and service line leaders during key leader transitions, and monitors actions taken to ensure completion of action plans.

The John D. Dingell VA Medical Center Director reviews organizational communication channels and ensures consistency with Veterans Health Administration High Reliability Organization goals and considers the use of Veterans Health Administration resources such as the Veterans Health Administration National Center for Organization Development.

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

Implement an improved inventory process to ensure that all connected devices used to support VA programs and operations are documented in the Enterprise Mission Assurance Support Service.

Ensure network infrastructure equipment is properly installed.

Ensure physical access controls are implemented for communication rooms.

Ensure a video surveillance system is operational and monitored for the data center.

Ensure communication rooms with infrastructure equipment have fire-detection and suppression systems.

Ensure water detection sensors are implemented in the data center.

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

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Protected Peer Review Committee recommends improvement actions for all Level 3 peer reviews.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs establish service-specific criteria for professional practice evaluations.

The VA St. Louis Health Care System Director conducts a fact-finding investigation asnecessary to determine whether the chief of the Emergency Department’s conduct wasinconsistent with VA policy and federal regulations and takes action as appropriate.

The VA St. Louis Health Care System Director establishes a standardized process for theadministration of the Columbia-Suicide Severity Rating Scale by Emergency Department staff topatients to maintain the integrity of the suicide risk screen.

The VA St. Louis Health Care System Director establishes a formal policy outliningexpectations for the monitoring of patients by Emergency Department nursing staff after triage.

The VA St. Louis Health Care System Director ensures root cause analyses and administrativeinvestigations are conducted efficiently and effectively if chartered for the same event as perVeterans Health Administration policy.

The VA St. Louis Health Care System Director ensures that institutional disclosures arecompleted within the time frame required by the Veterans Health Administration.

The VA St. Louis Health Care System Director ensures compliance with the Veterans HealthAdministration requirement for reporting healthcare professionals to the appropriate statelicensing board when indicated.

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.

Require purchase cardholders to submit a request for ratification for any unauthorized commitments identified.

Ensure the chief supply chain officer establishes local processes and procedures so that all necessary reports are routinely monitored on the Supply Chain Common Operating Picture, the Generic Inventory Package, or other inventory sites or software systems to ensure performance measures are maintained, as required in the Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.

Ensure supply chain managers implement a plan for staff training to increase awareness of internal controls and data reliability issues, such as conversion factor, within the Generic Inventory Package.

Ensure the chief of supply chain services provides quarterly physical inventory memoranda of “A” classified items to Veterans Integrated Service Network personnel, as required in the Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.

Ensure the chief supply chain officer reviews the facility item master file edit access list of all individuals at the VA medical facility who have permissions to enter or modify data within the item master file each calendar year, as required in the Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.

Develop formalized processes for monitoring and achieving identified efficiency targets and use available pharmacy data to make business decisions.

Establish measures to improve compliance with the VA directive to avoid end-of-year pharmaceutical purchases.

Develop a plan to align inventory management practices, such as the use of handheld scanners, bar code labeling, and ABC inventory analysis methodology with VHA policy.

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

The Director evaluates and determines additional reasons for noncompliance and ensures leaders evaluate sentinel events and conduct institutional disclosures when criteria are met.

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

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures electrical receptacles and switches in the mental health unit are covered by metal plates, secured by tamper-resistant screws, and receptacles are flush to the wall.

The VA Southern Nevada Healthcare System Director reviews processes in place to ensure proper response to future medical emergencies in outpatient clinics to include staff training, emergency notification systems, and emergency documentation processes.

The VA Southern Nevada Healthcare System Director reviews the process for and compliance with documentation of cardiopulmonary resuscitation in outpatient clinic settings, and takes action as indicated.

The VA Southern Nevada Healthcare System Director works with outpatient clinic leaders to ensure that all deficiencies identified in the after-action plan are completed and that compliance is monitored.

The VA Southern Nevada Healthcare System Director consults with Office of General Counsel’s Regional Counsel to review the incident and determine if an institutional disclosure is warranted and takes action accordingly.

The VA Southern Nevada Healthcare System Director completes an evaluation of staffs’ understanding of advance care planning, advance directives, and life-sustaining treatment decision processes, and takes action to address identified gaps.

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 Under Secretary for Health directs the Office of Primary Care and Office of Mental Health and Suicide Prevention to identify barriers to provider documentation of opioid use disorder in progress notes and implement solutions addressing these barriers.

The Under Secretary for Health ensures the Office of Primary Care and Office of Mental Health and Suicide Prevention determine impediments to maintaining accurate identification of opioid use disorder in electronic health record problem lists and implement policy and training to support accurate use of problem lists.

The Under Secretary for Health confirms the Office of Primary Care and Office of Mental Health and Suicide Prevention evaluate barriers affecting provider access and use of Department of Defense treatment records in Joint Longitudinal Viewer and implement solutions.

The Under Secretary for Health ensures the Office of Primary Care and Office of Mental Health and Suicide Prevention improve continuity of care by confirming providers are educated on the navigation and retrieval of Department of Defense treatment records in Joint Longitudinal Viewer.

The Under Secretary for Health requires the Assistant Under Secretary for Health for Clinical Services/Chief Medical Officer to evaluate and update processes for identification of veterans with a history of opioid use disorder for the provision of opioid overdose risk mitigation strategies.