All Reports

The Chief of Staff ensures service chiefs recommend continued privileges for licensed independent practitioners based on Ongoing Professional Practice Evaluation activities, and the Medical Executive Committee recommends them based on evaluation results.

The Deputy Medical Center Director ensures staff post biohazard signs in applicable areas.

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

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

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 all ambulatory care settings.

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

The Chief of Staff ensures the Clinical Executive Board reviews professional practice evaluation data for licensed independent practitioners.

The Chief of Staff ensures service chiefs include service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Medical Center Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on mental health inpatient unit sleeping room doors.

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.

The Chief of Staff ensures suicide prevention coordinators conduct, track, and report a minimum of five suicide prevention outreach activities each month.

The Chief of Staff ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.

The Chief of Staff ensures practitioners from other facilities with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations for solo licensed independent practitioners.

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

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

The Associate Director ensures staff maintain a safe environment by keeping walls in good repair.

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

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

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

The Medical Center Director ensures staff complete environment of care inspections in patient and non-patient care areas at the required frequency.

The Medical Center Director ensures staff cover electrical receptacles in the Inpatient Mental Health Unit common area with metal plates.

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

The Medical Center Director ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during Comprehensive Suicide Risk Evaluations.

The Chief of Staff ensures supervisors communicate the Peer Review Committee’s recommendations for all Level 3 peer reviews to providers and ensure they implement the improvement actions.

The Chief of Staff ensures the Medical Executive Council documents its review of licensed independent practitioners’ professional practice evaluations and recommend privileges based on the results.

The Executive Director ensures staff store reusable medical equipment in temperature- and humidity-controlled storage locations.

The Associate Director ensures staff keep storage rooms and areas used by patients clean and safe.

The Chief of Staff limits medication access to approved staff members.

The Associate Director ensures all toilet rooms within proximity to areas where pelvic examinations are performed, and all women’s, unisex, and family public restrooms have feminine hygiene products available at no cost.

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

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.

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

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

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.

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

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

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

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

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.

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

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

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

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

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.

The Medical Center Director ensures the Suicide Prevention Coordinator conducts at least five outreach activities each month.

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

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

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.

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

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

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.

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

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.

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

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.

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

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

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

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

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

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.

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

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

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

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

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

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.

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

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.

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

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

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

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

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

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

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.

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

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.

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

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

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.

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.

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.

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

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

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.

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

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

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

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

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.

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.

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.

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

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

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

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

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

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

The Director ensures staff store clean and dirty equipment separately.

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

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

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