All Reports

The Under Secretary for Health considers the need for a national policy establishing the inclusion of social determinants of health/health-related social needs into discharge assessment and planning.

The Under Secretary for Health considers the implementation of a standardized electronic health record template, such as the Assessing Circumstances and Offering Resources for Needs tool, that includes the assessment of social determinants of health/health-related social needs of hospitalized patients.

The Under Secretary for Health evaluates barriers to assessing social determinants of health/health-related social needs when patients are discharged from VA medical centers.

The Under Secretary for Health promotes the use of health equity tools across VA medical centers

The Under Secretary for Health promotes the establishment of partnerships of VA medical centers with community resources to address social determinants of health/health-related social needs.

The Under Secretary for Health, in conjunction with the National Oncology Program and Veterans Integrated Service Network directors, ensure facility leaders and staff are aware of the services offered to veterans diagnosed with breast cancer through the Women’s Oncology System of Excellence.

The Under Secretary for Health and National Oncology Program staff offer a range of services for patients diagnosed with breast cancer, including rehabilitative services, through the Women’s Oncology System of Excellence.

The Under Secretary for Health, Veterans Integrated Service Network directors, and facility leaders ensure staff enter data into the local cancer registry database in a timely manner.

The Under Secretary for Health reviews the criteria and processes used to identify and exclude healthcare providers removed from VA employment for violation of policy related to safe and appropriate care of veterans, and takes action as warranted.

The Under Secretary for Health reviews previous removals of healthcare providers from VA employment as required by VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 § 108 to determine whether the reason(s) for those removals were for violation of policy related to the safe and appropriate care of veterans, and takes action as warranted.

The Under Secretary for Health ensures Veterans Health Administration prescribers establish a diagnosis based on a complete and documented assessment prior to initiation of a stimulant to treat attention deficit hyperactivity disorder.

The Under Secretary for Health ensures Veterans Health Administration prescribers assess risks and contraindications associated with stimulant prescribing.

The Under Secretary for Health evaluates the prescription drug monitoring program query adherence goal for initial stimulant prescribing and takes action as warranted.

The Under Secretary for Health evaluates the adequacy of the referral processes related to complex mental health disorders, such as attention deficit hyperactivity disorder, and takes action as warranted.

The Under Secretary for Health considers establishing policy and clinical practice guidance related to attention deficit hyperactivity disorder diagnostic assessment and treatment with a stimulant and takes action as warranted.

The Under Secretary for Health examines potential differences between the veterans who reported to Sexual Assault Prevention and Response Office and used VA health care and those who did not in order to improve outreach efforts to the nearly half who did not engage with VA health care.

The Under Secretary for Benefits evaluates the service-connected disability application and claims process for veterans who reported sexual assault that occurred during military service to identify and mitigate potential barriers.

The Under Secretary for Benefits examines potential differences between the veterans who reported to Sexual Assault Prevention and Response Office and used VA benefits and those who did not in order to improve outreach efforts.

The Under Secretary for Health consider identifying a national program office to be responsible for oversight of alcohol withdrawal management across inpatient settings.

The Under Secretary for Health ensures the identified national program office responsible for oversight of alcohol withdrawal management consider requiring the development and implementation of written guidance for the management of alcohol withdrawal across all inpatient settings, to include: (a) expectations for determining alcohol withdrawal severity, level of care, and when transfer of care is indicated; (b) expected actions of nurses to communicate with prescribers based on patients’ changes in symptoms or alcohol withdrawal severity and when that communication should be followed by a prescribers face-to-face evaluation of a patient; (c) expectations for the evaluation of co-occurring conditions, expert consultation, and pharmacotherapy approaches; and (d) expectations for the collection and monitoring of outcome data for inpatient management of alcohol withdrawal at the national and healthcare system level.

The Under Secretary for Health consider the implementation of training for inpatient staff on the administration of standardized alcohol withdrawal severity scales.

The Under Secretary for Health makes certain the Veterans Health Administration complies with requirements that all acute sexual assault victim-survivors are offered prophylaxis for sexually transmitted infection when clinically indicated and monitors compliance.

The Under Secretary for Health verifies compliance with Veterans Health Administration requirements that all acute sexual assault victim-survivors are offered prophylaxis for pregnancy when clinically indicated and monitors compliance.

The Under Secretary for Health ensures all sexual assault victim-survivors are offered mental health resources, either directly through Veterans Health Administration or through the community and monitors compliance.

The Under Secretary for Health ensures compliance with Veterans Health Administration requirements for documentation of signature informed consent for forensic examinations conducted by staff at Veterans Health Administration facilities and monitors compliance.

The Under Secretary for Health coordinates with VA Office of Security and Law Enforcement to provide direction that facility policy or guidance include facility and jurisdiction-specific information necessary for frontline staff to act in accordance with jurisdiction and Veterans Health Administration requirements for VA police responding to sexual assaults.

The Under Secretary for Health ensures Veterans Health Administration’s policy specifies the required elements to include in Veterans Health Administration facilities’ policies or guidance on acute sexual assault, including jurisdiction-specific requirements, and considers an online national policy with an appendix containing each facility’s supplemental information.

The Under Secretary for Health makes certain that facility level management of acute sexual assault policy or guidance is updated to incorporate information on facility-specific resources and jurisdictional requirements as warranted, and educates staff as needed.

The Under Secretary for Health ensures that VA Police Chiefs review facility policy and guidance for police responding to sexual assaults and update to incorporate information on facility-specific resources and processes, including jurisdictional requirements, as warranted, and educates facility police officers as needed.

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 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 Under Secretary for Health evaluates the efficacy of the May 2022 Veterans Integrated Service Network and Office of Mental Health and Suicide Prevention oversight structure for suicide risk training and considers inclusion of an oversight structure for lethal means safety training compliance.

The Under Secretary for Health ensures clinician completion of comprehensive suicide risk evaluations including the discussion and documentation of firearms access and safe storage as required, and monitors compliance.

The Under Secretary for Health evaluates staff’s perceived barriers to completion of the suicide risk identification strategy and takes action as appropriate.

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.

The Deputy Secretary reviews the process that led to Oracle Cerner’s failure to inform VA of the unknown queue and takes action as indicated.

The Deputy Secretary evaluates the unknown queue technology and mitigation process and takes action as indicated.