Date Issued
|
Report Number
20-01994-18
|
Topics: Patient Safety
● Medical Staff Privileging Credentialing
● Military Sexual Trauma
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility-level senior leaders, ensures that summaries of the peer review committees’ work are reviewed quarterly by medical executive committees.
No. 2
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that all applicable deaths within 24 hours of admission are peer reviewed.
No. 3
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that cardiopulmonary resuscitation committees review each resuscitative episode under the facilities’ responsibility and include required elements in reviews.
No. 4
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures focused professional practice evaluation criteria are defined in advance.
No. 5
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures service chiefs include the minimum specialty criteria for focused professional practice evaluations of gastroenterology, pathology, nuclear medicine, and radiation oncology practitioners.
No. 6
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures executive committees of the medical staff document the decision to recommend continuing licensed independent practitioners’ privileges based on ongoing professional practice evaluation results.
No. 7
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that service chiefs’ privileging determinations are based, in part, on ongoing professional practice evaluation activities.
No. 8
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that ongoing professional practice evaluations use assessments by providers with similar training and privileges.
No. 9
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures facility clinical managers clearly define and share in advance the expectations, outcomes, and time frames for focused professional practice evaluations for cause with licensed independent practitioners.
No. 10
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that inventories of resources and assets that may be needed during an emergency are documented and reviewed annually.
No. 11
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that monthly and quarterly controlled substances inspection reports are reviewed at least quarterly by the facility committees responsible for quality oversight.
No. 12
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that electronic access for monitoring and performing controlled substances balance adjustments is limited to appropriate staff.
No. 13
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors complete monthly physical inspections of controlled substances storage areas on the day initiated.
No. 14
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify controlled substance orders for five randomly selected dispensing activities.
No. 15
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify that drugs listed on the “Destructions File Holding Report” are secured and documented and that there is a corresponding sealed evidence bag for each medication during monthly inspections.
No. 16
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify the inventory count for prescription pads on the day of monthly pharmacy inspections.
No. 17
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify written controlled substances prescriptions during monthly area inspections.
No. 18
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify pharmacy vault inventory at the required frequency.
No. 19
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors complete emergency drug cache inspections that include checks for lock tampering and verification of lock numbers.
No. 20
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinical managers implement processes for reviewing automated drug dispensing cabinet override reports.
No. 21
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures military sexual trauma coordinators establish and monitor related training.
No. 22
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures military sexual trauma coordinators communicate related issues, services, and initiatives to facility leaders.
No. 23
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures mental health and primary care providers complete mandatory military sexual trauma training within the required time frame.
No. 24
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinicians provide and document education on newly prescribed medications and assess patient/caregiver understanding of the information provided.
No. 25
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinicians review and reconcile patients’ medications and maintain and communicate accurate medication information in electronic health records.
No. 26
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure that women veterans health committees include required core members, meet at least quarterly, and report to leadership.
No. 27
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinical managers implement quality assurance processes that include tracking of cervical cancer screening notification and follow-up care.
No. 28
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that urgent care centers operating 24 hours a day, 7 days a week have an approved waiver from the National Director of Emergency Medicine.
No. 29
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that emergency departments and urgent care centers are staffed with a minimum of two registered nurses during all hours of operation.
No. 30
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure clinical managers maintain a backup call schedule for emergency department and urgent care center providers.
No. 31
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that support services, including social work, are available to emergency departments and urgent care centers during all hours of operation.
No. 32
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities use appropriate signage to direct patients to emergency departments and urgent care centers.