All Reports

The Facility Director reviews the more than 400 fecal immunochemical test specimens received by the laboratory to determine whether the processes completed were compliant with laboratory standards and policies, and ensures future specimens are received, accessioned, and processed by approved personnel.

The Veterans Integrated Service Network Director provides oversight of facility leaders’ thorough review of laboratory fecal immunochemical test processing practices to ensure laboratory staff confirm that fecal immunochemical test specimens include the date the patient collected the specimen, utilize the collection date to determine stability, and accurately record and process specimens with strict adherence to specimen stability standards and Veterans Health Administration and facility policies, and monitors compliance.

The Facility Director establishes a multidisciplinary team (laboratory, primary care, gastroenterology, quality) to conduct a system-wide evaluation of the fecal immunochemical test processes and practices across departments, identify areas for improvement (such as staff training, patient education, and standardized protocols), and implement recommended changes, and monitors for compliance and sustainment.

The Facility Director, in consultation with the Veterans Integrated Service Network’s Chief of Pathology and Laboratory Medicine Service, modifies the facility’s pre-printed fecal immunochemical test label to clearly identify a space and prompt for the patient to record the date the specimen was collected.

The Veterans Integrated Service Network Director, in consultation with the Pathology and Laboratory Medicine Service Program Office, Gastroenterology Program Office, and the Clinical Episode Review Team, evaluates the impact potential false-negative fecal immunochemical test results may have had on patients, and determines what measures need to be taken, including whether adverse event disclosures to patients are warranted.

Ensure that healthcare system finance office staff are made aware of policy requirements and that all accruals are proper and valid, as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”

Collaborate with the Veterans Integrated Service Network chief financial officer and network contracting office to establish a monthly prioritized listing of contract modifications and canceled orders for goods or services that have not been addressed by contracting officers to ensure modification actions are completed.

Ensure cardholders comply with prior approval, purchase card reconciliation, and record retention requirements as required by VA Financial Policy, vol. 16, chap. 1B, “Government Purchase Card for Micro-Purchases.”

Develop and implement processes to ensure all necessary reports are monitored routinely and appropriate steps are taken to ensure all supply chain performance measures are maintained in compliance with policy.

Develop and implement a plan to ensure data accuracy and reliability in the Generic Inventory Package in accordance with Veterans Health Administration policy.

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

Develop and implement a plan to achieve an inventory turnover rate closer to the Veterans Health Administration’s recommended level.

Ensure that pharmacy staff are trained on the ScriptPro workflow system for pharmacy.

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

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners 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 service chiefs incorporate service-specific criteria in the Ongoing 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 recommends continuation of privileges based on Ongoing Professional Practice Evaluation results.

The Assistant Director for Efficiency and Improvement evaluates and determines any additional reasons for noncompliance and ensures managers comply with inpatient mental health unit environmental safety requirements.

The Chief Medical Officer determines any additional reasons for noncompliance and reviews the credentials files and recommends VA appointments for physicians with a history of licensure action.

The Network Director evaluates and determines additional reasons for noncompliance and submits a Comprehensive Environment of Care compliance report to the Environment of Care Committee annually.

The System Director determines any additional reasons for noncompliance and ensures the Chief of Staff conducts institutional disclosures for applicable sentinel events.

The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete adverse event investigations within seven days and document appropriately in the Joint Patient Safety Reporting system, or the Patient Safety Manager monitors the investigations until they are completed.

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

The System Director evaluates and determines any additional reasons for noncompliance and ensures managers keep areas used by patients clean, safe, and suitable for the care, treatment, and services provided.

The System Director determines any additional reasons for noncompliance and ensures staff monitor and document VA police response times to panic alarm testing in the Mental Health Inpatient Unit on a regular basis.

The Medical Center Director ensures the Peer Review Committee submits accurate peer review summary analysis data quarterly to the Health Care Delivery Council.

The Medical Center Director ensures the Health Care Delivery Council reviews the Peer Review Committee’s summary analysis quarterly and determines actionable items.

The Medical Center Director ensures employees comply with safe work practices to eliminate or minimize exposure to potentially infectious materials.

The Medical Center Director ensures the Inpatient Unit Nurse Manager for the medical/surgical intensive care unit restricts access to clean and sterile storerooms to authorized personnel.

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

The Medical Center Director ensures providers complete Comprehensive Suicide Risk Evaluations following patients’ positive suicide risk screens.

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 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 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 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 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.