All Reports

Date Issued
|
Report Number
23-00107-135
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Suicide Prevention
Related Media: Facility Photo

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No. 1
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to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs incorporate service-specific criteria in professional practice evaluations.

No. 2
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to Veterans Health Administration (VHA)

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in ambulatory care settings.

Date Issued
|
Report Number
23-00098-151
|
Topics:  Medical Staff Privileging Credentialing ● Patient Safety
Related Media: Facility Photo

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No. 1
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to Veterans Health Administration (VHA)

The Executive Director ensures the Chief of Staff conducts institutional disclosures for applicable sentinel events.

No. 2
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to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs document Focused Professional Practice Evaluation results in licensed independent practitioners’ profiles.

Date Issued
|
Report Number
23-00108-149
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

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No. 1
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to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs document professional practice evaluation results in practitioners’ profiles, and the Medical Executive Committee reviews service chiefs’ recommendations along with clinical competence information when making privileging recommendations to the Director.

No. 2
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to Veterans Health Administration (VHA)

The Associate Director ensures staff keep patient care areas safe and clean.

No. 3
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to Veterans Health Administration (VHA)

The Director ensures staff regularly test panic alarms in the mental health inpatient unit and document VA police response times.

No. 4
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to Veterans Health Administration (VHA)

The Director ensures staff maintain a safe environment in the mental health inpatient unit.

No. 5
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to Veterans Health Administration (VHA)

The Director ensures staff maintain a safe environment in the Emergency Department for mental health patients.

No. 6
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to Veterans Health Administration (VHA)

The Chief of Staff ensures designated staff complete the 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.

Date Issued
|
Report Number
23-00118-157
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Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Suicide Prevention
Related Media: Facility Photo

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No. 1
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to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures the Veterans Integrated Service Network Chief Medical Officer oversees the hospital’s privileging process.

No. 2
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to Veterans Health Administration (VHA)

The Hospital Director ensures staff conduct environment of care inspections in non patient care areas at least once per fiscal year.

No. 3
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to Veterans Health Administration (VHA)

The Hospital Director ensures the suicide prevention team conducts a minimum of five outreach activities per month.

No. 4
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to Veterans Health Administration (VHA)

The Hospital Director ensures the suicide prevention coordinators report suicide related events monthly to mental health leaders and quality management staff.

No. 5
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to Veterans Health Administration (VHA)

The Hospital Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.

Date Issued
|
Report Number
23-00103-138
|
Topics:  Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

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No. 1
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to Veterans Health Administration (VHA)

The Chief of Staff ensures the Peer Review Committee recommends improvement actions for all peer reviews.

No. 2
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to Veterans Health Administration (VHA)

The Director ensures staff conduct environment of care inspections in patient care areas at least twice per fiscal year.

No. 3
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to Veterans Health Administration (VHA)

The Associate Director ensures staff maintain all medical equipment in accordance with manufacturers’ recommendations or use an alternative maintenance program that does not reduce the safety of the equipment.

No. 4
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to Veterans Health Administration (VHA)

The Chief of Staff ensures medications transported by the pneumatic tube system are only accessible by approved individuals.

No. 5
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to Veterans Health Administration (VHA)

The Associate Director ensures Environmental Management Services staff keep areas used by patients clean and orderly.

No. 6
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to Veterans Health Administration (VHA)

The Director ensures staff check over-the-door alarms in mental health inpatient units with corridor doors to patient sleeping rooms according to the manufacturer’s guidelines.

No. 7
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to Veterans Health Administration (VHA)

The Director ensures all entrances into mental health inpatient units have a sally port.

No. 8
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to Veterans Health Administration (VHA)

The Director ensures providers complete the Comprehensive Suicide Risk Evaluation the same day as a patient’s positive suicide risk screen in ambulatory care settings.

Date Issued
|
Report Number
23-00116-148
|
Topics:  Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

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No. 1
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to Veterans Health Administration (VHA)

The Medical Center Director ensures staff document VA police response times to panic alarm testing in the Inpatient Psychiatry Unit

No. 2
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to Veterans Health Administration (VHA)

The Medical Center Director ensures staff follow the manufacturer’s guidelines for checking over-the-door alarms for patient sleeping rooms in the Inpatient Psychiatry Unit.

No. 3
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to Veterans Health Administration (VHA)

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

No. 4
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to Veterans Health Administration (VHA)

The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.

Date Issued
|
Report Number
23-00024-133
|
Topics:  Medical Staff Privileging Credentialing ● Patient Safety
Related Media: Facility Photo

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No. 1
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to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs recommend continuation of current privileges based on Ongoing Professional Practice Evaluation activities

No. 2
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to Veterans Health Administration (VHA)

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

Date Issued
|
Report Number
23-00012-136
|
Topics:  Medical Staff Privileging Credentialing ● Patient Safety
Related Media: Facility Photo

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No. 1
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to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs recommend continued privileges based on Ongoing Professional Practice Evaluation activities

No. 2
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to Veterans Health Administration (VHA)

The Chief of Staff ensures the Executive Committee of the Medical Staff/Credentials Committee recommends continuation of licensed independent practitioners’ privileges based on Ongoing Professional Practice Evaluation results.

No. 3
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to Veterans Health Administration (VHA)

The Associate Director ensures staff check inventory in clean and sterile storerooms and remove expired or outdated items.

Date Issued
|
Report Number
23-00101-137
|
Topics:  Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures leaders conduct institutional disclosures for applicable sentinel events.

No. 2
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to Veterans Health Administration (VHA)

The Director ensures staff complete a root cause analysis for all events assigned an actual or potential safety assessment code score of 3.

No. 3
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to Veterans Health Administration (VHA)

The Associate Director ensures staff keep patient areas clean and free from undue wear.

No. 4
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to Veterans Health Administration (VHA)

The Director ensures staff check over-the-door alarms on the mental health inpatient unit according to the manufacturer’s guidelines.

No. 5
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to Veterans Health Administration (VHA)

The Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in ambulatory care settings.

Date Issued
|
Report Number
22-04014-130
|
Topics:  Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures leaders conduct institutional disclosures for applicable sentinel events.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures staff complete a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

No. 3
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to Veterans Health Administration (VHA)

The Associate Director ensures Environmental Management Service staff keep areas used by patients clean and orderly.

No. 4
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to Veterans Health Administration (VHA)

The Associate Director ensures staff keep furnishings and walls in good repair.

No. 5
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to Veterans Health Administration (VHA)

The Associate Director ensures staff use solid bottom shelves in storage areas.

No. 6
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to Veterans Health Administration (VHA)

The Associate Director ensures staff inspect, test, and maintain medical equipment.

No. 7
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to Veterans Health Administration (VHA)

The Associate Director ensures staff document VA police response times for panic alarm testing in the mental health inpatient unit.

No. 8
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to Veterans Health Administration (VHA)

The Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to quality management staff.

Date Issued
|
Report Number
23-00013-128
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

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No. 1
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to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs report Focused Professional Practice Evaluation results to an executive committee of the medical staff for consideration in privileging recommendations.

No. 2
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to Veterans Health Administration (VHA)

The Director ensures staff conduct environment of care inspections in patient care areas as required.

No. 3
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to Veterans Health Administration (VHA)

The Director ensures staff test panic alarms in the Inpatient Psychiatry Unit at least quarterly and record testing in a log, including police response times.

No. 4
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to Veterans Health Administration (VHA)

The Director ensures staff test over-the-door alarms in the Inpatient Psychiatry Unit per the manufacturer’s recommendations.

No. 5
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to Veterans Health Administration (VHA)

The Director ensures staff keep interior spaces in the Inpatient Psychiatry Unit safe and suitable for care.

No. 6
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to Veterans Health Administration (VHA)

The Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.

Date Issued
|
Report Number
23-00016-132
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

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No. 1
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to Veterans Health Administration (VHA)

The Chief of Staff ensures staff record the Peer Review Committee’s formal discussions related to changes in peer review level assignments in the meeting minutes.

No. 2
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to Veterans Health Administration (VHA)

The Chief of Staff ensures the Medical Staff Executive Committee reviews data provided by the Peer Review Committee to determine the need for further action.

No. 3
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to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs complete Ongoing Professional Practice Evaluations prior to reprivileging to ensure continuous delivery of quality care.

No. 4
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to Veterans Health Administration (VHA)

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

No. 5
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to Veterans Health Administration (VHA)

The Associate Director ensures the Comprehensive Environment of Care Rounds Coordinator or designee schedules environment of care inspections and staff complete and document them at the required frequency.

No. 6
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to Veterans Health Administration (VHA)

The Associate Director ensures staff keep patient care areas safe and clean.

No. 7
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to Veterans Health Administration (VHA)

The Medical Center Director ensures staff document police response times to panic alarm testing in the mental health inpatient unit.

No. 8
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to Veterans Health Administration (VHA)

The Medical Center Director ensures staff test over-the-door alarms based on the manufacturer’s recommendations for mental health inpatient unit sleeping rooms.

No. 9
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to Veterans Health Administration (VHA)

The Medical Center Director ensures staff check all mental health inpatient unit ceiling tiles semiannually.

No. 10
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to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures the Medical Center Director has sufficient biomedical staff and confirms they inspect and test all medical equipment for scheduled maintenance.

No. 11
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to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures compliance with VHA Directive 1860, Biomedical Engineering Performance Monitoring and Improvement, for oversight structure of the medical center’s biomedical program.

No. 12
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to Veterans Health Administration (VHA)

The Medical Center Director ensures designated staff complete the Comprehensive Suicide Risk Evaluation on the same calendar day as a positive suicide risk screen, when clinically appropriate, for all ambulatory care patients.

Date Issued
|
Report Number
22-04112-125
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

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No. 1
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to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs define the time frames for Focused Professional Practice Evaluations.

No. 2
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to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs recommend reprivileging based, in part, on Ongoing Professional Practice Evaluation activities

No. 3
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to Veterans Health Administration (VHA)

The Director ensures staff remove corrugated containers from patient care areas.

No. 4
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to Veterans Health Administration (VHA)

The Director ensures staff keep storerooms clean and free of visible dust and soiling.

No. 5
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to Veterans Health Administration (VHA)

The Director ensures Environmental Management Services staff keep patient care areas clean.

No. 6
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to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services ensures staff remove expired commercial products from patient care areas.

No. 7
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to Veterans Health Administration (VHA)

The Director ensures staff store clean and dirty equipment separately.

No. 8
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to Veterans Health Administration (VHA)

The Director ensures staff maintain walls to allow for thorough cleaning.

No. 9
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to Veterans Health Administration (VHA)

The Associate Director ensures staff test over-the-door alarms in the Inpatient Mental Health unit per the manufacturer’s recommendations.

No. 10
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to Veterans Health Administration (VHA)

The Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.

Date Issued
|
Report Number
23-00109-121
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

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No. 1
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to Veterans Health Administration (VHA)

The Medical Center Director ensures leaders identify and evaluate sentinel events and conduct and document institutional disclosures when criteria are met.

No. 2
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to Veterans Health Administration (VHA)

The Medical Center Director ensures staff complete a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

No. 3
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to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs recommend reprivileging for licensed independent practitioners based, in part, on Ongoing Professional Practice Evaluation data.

No. 4
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to Veterans Health Administration (VHA)

The Chief of Staff ensures staff report licensed independent practitioners’ Focused Professional Practice Evaluation results to the Clinical Executive Board.

No. 5
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to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Chief Medical Officer provides effective oversight of credentialing and privileging processes at the healthcare system.

No. 6
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to Veterans Health Administration (VHA)

The Medical Center Director ensures the comprehensive environment of care coordinator schedules environment of care inspections at the required frequency and verifies staff complete and document them.

No. 7
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to Veterans Health Administration (VHA)

The Medical Center Director ensures staff document police response times to panic alarm testing in the Inpatient Mental Health Unit.

No. 8
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to Veterans Health Administration (VHA)

The Medical Center Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on Inpatient Mental Health Unit sleeping room doors.

No. 9
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to Veterans Health Administration (VHA)

The Medical Center Director ensures staff maintain a safe environment in the Inpatient Mental Health Unit.

No. 10
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to Veterans Health Administration (VHA)

The Medical Center Director ensures staff post hazard warning signs on all access doors where potentially infectious materials are located.

No. 11
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to Veterans Health Administration (VHA)

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

No. 12
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to Veterans Health Administration (VHA)

The Chief of Staff ensures designated staff complete the 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.

Date Issued
|
Report Number
23-00111-119
|
Topics:  Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

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No. 1
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to Veterans Health Administration (VHA)

The Medical Center Director ensures staff identify sentinel events and take appropriate action when home oxygen fires occur.

No. 2
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to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures network staff track and monitor home oxygen vendor completion of root cause analyses when sentinel events occur.

No. 3
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to Veterans Health Administration (VHA)

The Chief of Staff ensures designated staff complete the 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.

Date Issued
|
Report Number
23-00096-122
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Suicide Prevention
Related Media: Facility Photo

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No. 1
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to Veterans Health Administration (VHA)

The Chief of Staff ensures providers with equivalent specialized training and similar privileges complete licensed independent practitioners’ Ongoing Professional Practice Evaluations.

No. 2
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to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs recommend continued privileges for licensed independent practitioners based, in part, on Ongoing Professional Practice Evaluation activities.

No. 3
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to Veterans Health Administration (VHA)

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in ambulatory care settings.

Date Issued
|
Report Number
23-00097-113
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Suicide Prevention
Related Media: Facility Photo

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No. 1
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to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs regularly complete Ongoing Professional Practice Evaluations for each licensed independent practitioner.

No. 2
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to Veterans Health Administration (VHA)

The Chief of Staff ensures the Executive Committee of the Medical Staff reviews Ongoing Professional Practice Evaluation data and documents its review prior to recommending licensed independent practitioners’ ongoing privileges to the Director.

No. 3
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to Veterans Health Administration (VHA)

The Director ensures staff complete environment of care inspections at the required frequency.

No. 4
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to Veterans Health Administration (VHA)

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation the same calendar day as a patient’s positive suicide risk screen in all ambulatory care settings.

Date Issued
|
Report Number
23-00122-118
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Suicide Prevention
Related Media: Facility Photo

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No. 1
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to Veterans Health Administration (VHA)

The Chief of Staff ensures medical staff review and document licensed independent practitioners’ Focused Professional Practice Evaluation results and report them to the Medical Executive Board.

No. 2
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to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs monitor licensed independent practitioners’ performance by regularly conducting Ongoing Professional Practice Evaluations.

No. 3
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to Veterans Health Administration (VHA)

The Medical Center Director ensures staff conduct environment of care inspections in patient care areas at the required frequency.

No. 4
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to Veterans Health Administration (VHA)

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

No. 5
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to Veterans Health Administration (VHA)

The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.