All Reports

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.

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

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.

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

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

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

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.

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

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.

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

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

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

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

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

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 providers with equivalent specialized training and similar privileges complete licensed independent practitioners’ Ongoing Professional Practice Evaluations.

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

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

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.

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

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.

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.

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

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

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

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

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

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

The Chief of Staff ensures the Suicide Prevention Coordinator reports suicide-related events monthly to mental health leaders and quality management staff.

The Director ensures the Patient Safety Manager documents start dates for sentinel event investigations in the Joint Patient Safety Reporting system.

The Director ensures the Patient Safety Manager initiates a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

The Director ensures executive leaders consolidate all credentialing and privileging activities into one credentialing and privileging office under the Chief of Staff.

The Director ensures the Credentialing and Privileging Manager reports directly to the Chief of Staff.

The Director 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 the Medical Executive Council reviews results of professional practice evaluations.

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete licensed independent practitioners’ professional practice evaluations.

The Veterans Integrated Service Network Director ensures the Veterans Integrated Service Network Chief Medical Officer provides oversight of the medical center’s privileging process.

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

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

The Medical Center Director 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 Director ensures staff complete individual root cause analyses for all adverse patient safety events with an actual or potential safety assessment code score of 3.

The Chief of Staff ensures service chiefs maintain sufficient data for licensed independent practitioners’ Ongoing Professional Practice Evaluations.

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

The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.

The Medical Center Director ensures staff complete a minimum of eight patient safety analyses each year.

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete Focused and Ongoing Professional Practice Evaluations.

The Chief of Staff ensures service chiefs complete licensed independent practitioners’ Ongoing Professional Practice Evaluations on a regular basis.

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

The Medical Center 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 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 Executive Director ensures Supply Chain Management, Engineering, or Facility Management Service staff monitor temperature and humidity in all clean and sterile storage rooms to maintain a stable environment.

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

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

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

The Associate Director ensures staff store clean and dirty equipment and supplies separately.

The Associate Director ensures staff place all examination tables with the foot facing away from the door.

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

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