All Reports

Better Coordination Needed to Negotiate Consistent Prices for Prescription Eyeglasses
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21-02984-179
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Topics: Care Coordination,Community Care,Contract Integrity,Patient Care Services Operations

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Coordinate with the executive director of the Prosthetic and Sensory Aids Service and officials from the Veterans Health Administration’s Procurement and Logistics Office and the VA Office of Acquisition, Logistics, and Construction to develop and implement a sourcing strategy, such as national contracts or a pricing catalog across all contracts by vendor for eyeglasses prescribed by a VA provider.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Coordinate with the executive directors of the Prosthetic and Sensory Aids Service and the Veterans Health Administration’s Office of Procurement to implement a process to ensure contracting officers coordinate before awarding any Veterans Integrated Service Network–level contracts for eyeglasses to make sure these vendors offer the Veterans Health Administration the best pricing that is also consistent for the same or similar items to the extent possible.

Total Monetary Impact of All Recommendations
Open: $ 6,500,000.00
Closed: $ 0.00
Improvements Needed in Lung Cancer Screening Through Use of Community Care
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22-00416-10
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Topics: Care Coordination,Community Care

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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.

Noncompliance with Community Care Referrals for Substance Abuse Residential Treatment at the VA North Texas Health Care System
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21-03864-34
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Topics: Mental Health,Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA North Texas Health Care System Director ensures that staff provide alternative treatment options, including community residential care referrals, when Veterans Health Administration admission wait time for substance abuse disorder residential rehabilitation treatment exceeds 30 days, and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA North Texas Health Care System Director conducts a comprehensive review of the management of community residential care referrals and takes action as warranted.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health ensures that Veterans Integrated Service Network leaders provide adequate oversight to ensure adherence to the mental health residential rehabilitation treatment program access to care policy as required.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA North Texas Health Care System Director makes certain that the Bonham Substance Abuse Residential Rehabilitation Treatment Program procedures are consistent with Veterans Health Administration scheduling requirements, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health strengthens mental health treatment coordinator assignment procedures for patients awaiting mental health residential rehabilitation treatment program admission as warranted.
Care in the Community Healthcare Inspection of VA Southeast Network (VISN 7)
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21-01823-31
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Topics: Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VISN 7 Director ensures VISN leaders, providers, and program staff monitor the quality of contracted clinical services for patients receiving non-VA home dialysis services.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The VISN 7 Director ensures that ordering providers communicate normal mammography results to patients within 14 calendar days.
Care in the Community Healthcare Inspection of VA Heartland Network (VISN 15)
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21-01821-08
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Topics: Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VISN 15 Network Director ensures that an end-stage renal disease provider sees patients enrolled in the home dialysis program at least monthly, as evidenced by a progress note placed in the medical record and endorsed by the responsible independent renal practitioner.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VISN 15 Network Director makes certain that staff ensure home visits are performed prior to accepting patients into the home dialysis program, and at least annually thereafter.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VISN 15 Network Director ensures VISN leaders and clinicians monitor the quality of contracted clinical services for patients receiving non-VA home dialysis services.
Community Care Coordination Delays for a Patient with Oral Cancer at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas
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21-02326-233
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Topics: Community Care,Care Coordination,Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Health Care System of the Ozarks Facility Director ensures that Office of Community Care staff take action on active consults within seven days and schedule community care appointments within the 30-day clinically indicated date requirement and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Health Care System of the Ozarks Facility Director evaluates the process for authorization of requests for community care and for coordinating care for patients receiving oncology treatment in the community, and takes corrective action to address any deficiencies identified.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary of Health ensures the Veterans Health Administration Office of Community Care defines a standardized process for community care coordination related to follow-up requests for additional services from community providers.
Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia
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21-03349-186
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Topics: Care Coordination,Community Care,Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director ensures that providers communicate, act on, and document a review of test results consistent with Veterans Health Administration policy.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director determines why the abnormal prostate-specific-antigen test results were not alerted to an ordering or surrogate provider and if other patient test results during that time frame also warrant review.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director ensures that abnormal test results are timely communicated to providers or providers’ surrogates.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director reviews the urology consult template and, if appropriate, ensures the specific imaging required for consultation is specified in the template.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director ensures that procedures are in place to identify and reduce errors when staff place nuclear medicine orders.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director ensures that facility staff submit patient safety reports consistent with Veterans Health Administration and Hampton VA Medical Center policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director ensures that quality management staff initiate timely quality reviews when deficiencies in patient care are identified.
VHA Continues to Face Challenges with Billing Private Insurers for Community Care
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21-00846-104
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Topics: Community Care,Financial Management

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Maximize opportunities to bill veterans’ private health insurers for recoverable claims by developing procedures that align and prioritize the processing of such claims to insurers’ filing deadlines.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Strengthen information system controls to make certain that complete and accurate claims information is transferred between applicable current and future Community Care payment systems and the Consolidated Patient Account Centers’ workflow tool and VistA patient treatment files.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Conduct an assessment to determine if staffing resources and workload are sufficiently aligned to process the anticipated volume of claims to be billed to veterans’ private health insurers and make adjustments as needed.
Total Monetary Impact of All Recommendations
Open: $ 805,200,000.00
Closed: $ 0.00
Care in the Community Healthcare Inspection of VA Midwest Health Care Network (VISN 23)
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21-01820-159
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Topics: Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VISN 23 Director ensures implementation and sustainment of initial and annual home visits for patients accepted into the VISN 23 home dialysis program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VISN 23 Director ensures the implementation and sustainment of quality monitoring of contracted clinical services for home dialysis.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VISN 23 Director ensures that VA providers receive mammography reports from non-VA providers within the established acceptable timeframe.
Atlanta VA Health Care System’s Unopened Mail Backlog with Patient Health Information and Community Care Provider Claims
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21-03916-103
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Topics: Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The director of VISN 7 ensures the Atlanta VA Health Care System develops and implements a plan for the routine proper and prompt processing of mail. That plan should include adequate staffing of the mailroom and sufficient training for mailroom personnel.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The director of VISN 7 assists the Atlanta VA Health Care System in taking steps when appropriate to recoup money owed from expired checks that were identified in the mail backlog.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The under secretary for health assess the negative effects of this mail backlog on veterans, community care providers, and other parties, and where possible take steps to remedy those effects.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The under secretary for health determines if unprocessed mail backlogs exist at other VA medical facilities.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The under secretary for health develops procedures and controls to make certain that medical facility personnel taking over POM on-site mail processing have the necessary resources and expertise to accomplish this work accurately and within prescribed timelines.
Care in the Community Consult Management During the COVID-19 Pandemic at the Martinsburg VA Medical Center in West Virginia
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21-01724-84
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Topics: COVID-19,Community Care,Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Integrated Service Network Director confirms that weekly calls with facility and Veterans Integrated Service Network leaders are held to discuss active Improvement Action Plans, progress made, timelines, and next steps.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Martinsburg VA Medical Center Director verifies that Improvement Action Plans, identifying areas of improvement and outlining recommendations, are in place for unmet national Care in the Community performance metrics.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Martinsburg VA Medical Center Director ensures COVID Priority 1 consults are run and reviewed by Care in the Community managers and staff daily.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Martinsburg VA Medical Center Director confirms that clinical reviews of COVID Priority 1 active consults are completed and documented, monitors compliance, and takes action as warranted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Martinsburg VA Medical Center Director ensures a process is in place to review and address consults for patients who died prior to being scheduled or seen by a community care provider to determine if an adverse event occurred as a result of a delay in processing a patient’s consult.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Martinsburg VA Medical Center Director evaluates the effectiveness of strategies to manage the backlog of active consults and the use of urgent and emergent to prioritize consults for scheduling, determines if changes in practice are warranted, and documents the agreed upon process.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Martinsburg VA Medical Center Director conducts a review to determine who, outside Care in the Community staff, is facilitating appointment scheduling and evaluates if the scheduling assistance of other services is an effective use of resources, and establishes a standardized process to align practices.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Martinsburg VA Medical Center Director ensures Care in the Community staffing levels are adequate to support the processing of consults according to time frames set by the Veterans Health Administration.
Audit of Community Care Consults during COVID-19
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21-00497-46
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Topics: COVID-19,Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Develop guidelines requiring supervisors to use VHA systems to monitor documentation of efforts to contact patients to schedule an appointment and to take corrective action as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Establish a tool to monitor whether clinicians are properly indicating the appropriateness of alternative forms of care and whether staff offered them to patients when clinically appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Reassess the frequency of and approach to its training for scheduling community care consults to VHA facilities as revisions are made to the various tools.
VHA Improperly Paid and Reauthorized Non-VA Acupuncture and Chiropractic Services
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20-01099-249
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Topics: Community Care,Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Ensure the Office of Community Care implements automated payment system controls to reject non VA claims that exceed the number of authorized visits or cutoff dates or includes treatment codes that deviate from established standards for care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Ensure the Office of Community Care conducts ongoing payment system audits to identify and minimize improper payments of unauthorized claims.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Direct the Health Information Management program office in coordination with the Office of Community Care and facility chiefs of staff to ensure facilities are conducting post payment audits of billed acupuncture and chiropractic services to verify non VA providers are properly supporting their claims and to develop processes for corrective actions based on audit results.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Ensure the Office of Community Care and the Health Information Management program office, in coordination with the offices of Acupuncture and Chiropractic services, make any current and future continuing education material related to documenting acupuncture and chiropractic services available to non VA providers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Direct facility chiefs of staff to require those authorized to approve non VA care to document review of prior care before approving additional services.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Instruct facility chiefs of staff to require VA providers to document their clinical justification for additional care requested by a veteran.
Total Monetary Impact of All Recommendations
Open: $ 341,700,000.00
Closed: $ 0.00
VHA Risks Overpaying Community Care Providers for Evaluation and Management Services
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21-01807-251
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Topics: Community Care,Financial Management

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Direct the Health Information Management program office, in coordination with the Office of Community Care and facility chiefs of staff, to ensure facilities are conducting post payment audits of billed evaluation and management services to verify non VA providers are properly supporting their claims, including a focus on providers who frequently bill high level evaluation and management services and/or submit charges during periods when global surgery packages are in effect, and develop processes for corrective actions based on audit results.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Ensure the Office of Community Care and the Health Information Management program office make any current and future continuing education material related to documenting evaluation and management services available to non VA providers.
Total Monetary Impact of All Recommendations
Open: $ 59,600,000.00
Closed: $ 0.00
Deficiencies in Select Community Care Consult (Stat) Processes During the COVID-19 Pandemic
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20-03437-26
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Topics: COVID-19,Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates community care resources, facility practices, and Veterans Health Administration requirements related to stat community care consult processes and takes action as warranted to ensure that patients receive clinically indicated care in the appropriate time frame
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health clarifies guidance to VA medical facilities for stat community care consults including the timeliness of clinical review and approval, retrieval of medical records, and administrative closure.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health issues guidance to VA medical facilities regarding the override process for stat community care consults to include collaboration expected between the referring provider and the designee.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates patient involvement in decision-making regarding clinical reviewers’ modification of the urgency status of stat community care consults to determine if the process is in alignment with Veterans Health Administration patient-centered care goals and takes action as warranted.
No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates the time frame for adjudicating and communicating clinical appeals, determines applicability to the 24-hour requirement for completing stat community care consults, and takes action as warranted.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates adverse event reporting processes in community care, including a review of guidance provided in the VHA National Patient Safety Improvement Handbook, 1050.01 and the VHA Patient Safety Events in Community Care: Reporting, Investigation and Improvement Guidebook for inconsistencies and takes action as warranted.
Deficiencies in Coordination of Care for Patients with Treatment-Resistant Depression at the VA San Diego Healthcare System in California
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20-03359-220
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Topics: Mental Health,Community Care,Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health requires that all community care providers authorized to provide ketamine or esketamine for treatment-resistant depression receive and review VA’s National Protocol Guidance on ketamine infusion and intranasal esketamine.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates the need for conducting research on the use of ketamine and esketamine for treatment-resistant depression including the comparative efficacy of ketamine and esketamine, the effect of route of administration, therapeutic dose range, mechanism of action, and efficacy and safety of long-term treatment, and initiates research efforts as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA San Diego Healthcare System Director confirms that the facility’s Community Care Service takes timely actions to ensure that administrative processes for care authorization do not disrupt continuity of clinical care.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA San Diego Healthcare System Director makes certain that the facility’s Community Care Service processes incorporate relevant clinical service input in decisions regarding authorization, denial, or discontinuation of care.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA San Diego Healthcare System Director ensures that the facility’s Community Care Service processes incorporate a consistent mechanism for communication with Veterans Health Administration and community clinical providers and patients to facilitate well-timed coordination of care.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA San Diego Healthcare System Director monitors implementation of the coordinated, clinically informed plans for continuing care when transitioning the remaining patients from ketamine treatment in the community to care at the facility.
Deficiencies in the Completion of Community Care Consults and Leaders’ Oversight at the New Mexico VA Health Care System in Albuquerque
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20-00716-177
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Topics: Community Care,Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The New Mexico VA Health Care System Director verifies monitoring is in place to ensure that clinical documentation is obtained from non-VA providers, scanned into the electronic health record, and attached to the applicable consult prior to completion of the consult.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The New Mexico VA Health Care System Director evaluates program effectiveness and monitors the Chief of Community Care’s implementation of the competency and training program for Community Care Service nurses.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The New Mexico VA Health Care System Director confirms the Consult and Access Management Steering Committee updates its charter and oversees all aspects of the consult process as required by the Veterans Health Administration consult management policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The New Mexico VA Health Care System Director determines that staff responsible for monitoring and oversight, as identified by the Chief of Staff and the Consult and Access Management Steering Committee, develop and implement a process to evaluate Community Care consult processes and procedures for consistency with Veterans Health Administration policies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The New Mexico VA Health Care System Director reviews the organizational structure of the facility’s Community Care Department, including available positions, evaluates the expertise of leaders and supervisory staff to ensure effective management and oversight, and takes action as necessary.
Improvements Needed in Adding Non-VA Medical Records to Veterans’ Electronic Health Records
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19-08658-153
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Topics: Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Ensure facilities create and implement standard operating procedures that clearly define all Health Information Management and community care staff responsibilities and the procedures for accurately scanning, importing, and indexing non-VA medical records.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Require facility directors ensure that Health Information Management leaders provide or formally delegate training, quality checks, and quality assurance monitoring for community care staff responsible for medical record management.
Deficiencies in Care and Administrative Processes for a Patient Who Died by Suicide, Phoenix VA Health Care System, Arizona
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20-02667-93
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Topics: Mental Health,Suicide Prevention,Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Phoenix VA Health Care System Director conducts a full review of the patient’s care to determine if administrative action is warranted, consulting with Human Resources and General Counsel offices as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Phoenix VA Health Care System Director ensures that staff complete suicide risk assessments consistent with Veterans Health Administration and Phoenix VA Health Care System policies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Phoenix VA Health Care System Director ensures timely and accurate completion of electronic health record documentation.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Phoenix VA Health Care System Director evaluates the community care psychology consult authorization timeliness and takes action as warranted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Phoenix VA Health Care System Director conducts a review of Primary Care Clinic missed appointment procedures and ensures patient follow-up and staff training, as appropriate.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Phoenix VA Health Care System Director evaluates scheduling accuracy of mental health community care psychology consults and takes action as appropriate.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Phoenix VA Health Care System Director ensures timely completion of behavioral health autopsies, consistent with Veterans Health Administration policy, and monitors for ongoing compliance.
View Alert Process Failures and the Impact on Patient Care at the Central Alabama Veterans Health Care System in Montgomery
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20-00427-92
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Topics: Patient Safety,Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health maintains consistent acting or interim leaders and expedites hiring of permanent leaders at the Central Alabama Veterans Health Care System.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Southeast Network Director ensures continued collaboration with the Central Alabama Veterans Health Care System to facilitate compliance with guidelines related to view alert management and monitors for ongoing efficiency and sustainability.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Central Alabama Veterans Health Care System Director will continue to evaluate and assess the Central Alabama Veterans Health Care System’s view alert management process, effectiveness of its action plan, and modify as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Central Alabama Veterans Health Care System Director ensures that initial and ongoing provider training and support for the clinical management of view alerts is provided, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Central Alabama Veterans Health Care System Director issues guidance and ensures providers are trained on a clearly defined process for the designation of surrogates and the associated responsibilities, and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Central Alabama Veterans Health Care System Director evaluates the two cases discussed in this report to determine if an institutional disclosure or formal quality management review is needed and takes action accordingly.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Central Alabama Veterans Health Care System Director conducts a retrospective review focusing on the unmanaged abnormal laboratory test and imaging results to include those that have the most potential for adverse clinical outcomes to ensure patients received follow-up care as required by Veterans Health Administration policy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Central Alabama Veterans Health Care System Director conducts a retrospective review focusing on unscheduled community care consults that were discontinued after 90 days that have the most potential for adverse clinical outcomes to ensure patients received follow-up care as required by Veterans Health Administration policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Central Alabama Veterans Health Care System Director ensures the development and implementation of a policy to address the communication of all test results to ordering providers, or designee, and to patients as required by Veterans Health Administration policy, and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Central Alabama Veterans Health Care System Director ensures that audits of abnormal laboratory and imaging test results, and unscheduled community care consults that were discontinued after 90 days, are completed to verify providers have managed the associated view alerts, and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Central Alabama Veterans Health Care System Director ensures that pending actions are completed for the 33 patient cases with clinical issues referred to the system by the Office of the Inspector General.
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