All Reports

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures medical facility directors make certain that a written policy is in place and implemented for the safe, appropriate, orderly, and timely transfer of patients.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures chiefs of staff and associate directors of patient care services monitor and evaluate all transfers as part of Veterans Health Administration’s Quality Management Program.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain chiefs of staff ensure that transferring providers send patients’ active medication lists and copies of advance directives to receiving facilities during inter-facility transfers.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain chiefs of staff and associate directors of patient care services ensure nurse-to-nurse communication occurs during the inter-facility transfer process.

Implement electronic system enhancements to require claims processors to identify relevant evidence before a medical opinion request can be submitted.

Strengthen monitoring controls by improving the national and local quality review processes to identify medical opinion request areas in need of improvement and demonstrate progress toward ensuring compliance with established procedures.

Assess whether an enhancement to the Quality Management System could mitigate the risk of claims processors closing special-focused review errors without correction and develop a process to ensure corrective actions are taken on all errors.

Establish clear oversight roles and responsibilities of the program office and of regional network telehealth and medical facility leads to monitor medical facility social worker and telehealth staff compliance with the “Digital Divide Standard Operating Procedure” for conducting assessments, ordering, and scheduling.

Develop and implement a mechanism to alert the requesting clinic that a patient has a loaned device and can now be scheduled for a VA Video Connect appointment.

Update the digital divide consult training to include procedure updates and ensure social workers and facility telehealth and Remote Order Entry System coordinators who process digital divide consults and video device orders complete the training and take refresher training as needed.

Implement procedures to require responsible staff to check for duplicate devices before submitting a device order consult.

Establish an alert in the Remote Order Entry System to notify the responsible staff member that a patient already has an issued device before ordering another, and initiate retrieval activities for duplicate devices.

Delegate in the “Digital Divide Standard Operating Procedure” facility staff to monitor the tablet dashboard for VA Video Connect appointment activity and device use, and clearly define regional network telehealth leads’ oversight responsibilities to ensure facilities initiate retrieval activities when warranted.

Establish an automated mechanism using the tablet dashboard to routinely identify the devices that meet retrieval priorities and also initiate retrieval of those that already meet retrieval requirements.

Address restrictions in the refurbishment process, implement accessible and trackable reporting of devices waiting to be refurbished, and implement a structured purchasing model to guide new device purchases and maintain an appropriate inventory level.

Provide appropriate oversight and ensure coordination between designated program offices to implement a comprehensive identity, credential, and access management policy.

Update and publish a VA directive and handbook associated with identity and access management that includes current National Institute of Standards and Technology requirements.

Implement a formal procedure to ensure all improperly created debts identified by the review team are corrected, and certify the results to the OIG.