All Reports

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

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

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

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

The Executive Medical Center Director ensures appropriate personnel install over-the-door alarms for sleeping room doors in the mental health inpatient unit.

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

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

The Executive 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 on the same calendar day as a positive suicide risk screen, when logistically feasible and clinically appropriate, for all ambulatory care patients.

The Chief of Staff ensures the Suicide Prevention Coordinator conducts, tracks, and reports a minimum of five suicide prevention outreach activities monthly.

The Director ensures staff keep all areas clean and safe.

The Director ensures staff keep the medical center well maintained.

The Chief of Pharmacy Services limits medication access to approved staff members.

The Director ensures staff store sterile supplies in temperature- and humidity-controlled storage rooms.

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

The Director ensures providers notify the suicide prevention team of patients who report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.

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

The Veterans Integrated Service Network Director ensures external practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations for practitioners in “two-deep” services or specialties.

The Medical Center Director ensures the Safety and Occupational Health Specialist or designee tracks environment of care inspection deficiencies until they are resolved.

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

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

The Director ensures staff have written procedures for responding to utility system disruptions.

The Director ensures staff identify, minimize, or eliminate safety and security risks in the physical environment.

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 Director ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.

The Network Director determines the reasons for noncompliance and ensures the Patient Safety Officer collects, analyzes, and acts on peer review summary data.

The Chief Medical Officer determines any additional reasons for noncompliance and reviews the credentials file and makes a recommendation on continuing the appointment process for physicians with a potentially disqualifying licensure action.

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

The Medical Center Director ensures the Safety and Occupational Health Specialist or designee schedules and ensures staff complete and document environment of care inspections at the required frequency.

The Medical Center Director ensures staff monitor and document VA police response times to panic alarm testing in the Acute Inpatient Mental Health Unit at least quarterly.

The Medical Center Director ensures the Suicide Prevention Coordinator conducts a minimum of five outreach activities each month.

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

The Director ensures staff track deficiencies identified during comprehensive environment of care inspections through resolution.

The Director ensures staff maintain a safe and clean environment.

The Executive Director ensures staff complete peer reviews for unanticipated deaths occurring within 24 hours of admission.

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

The Chief of Staff ensures providers with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of 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 Associate Director ensures managers maintain a safe and clean environment throughout the medical center.

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a positive suicide risk screen when it is clinically appropriate.

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

The Chief of Staff ensures clinical staff notify the suicide prevention team if patients report suicidal or other self-directed violent behaviors that occurred in the 12 months preceding the Comprehensive Suicide Risk Evaluation.

The Chief of Staff ensures leaders appoint one full-time suicide prevention coordinator to each community-based outpatient clinic that serves at least 10,000 unique veterans annually.

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

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

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same calendar day, when it is clinically appropriate, following a positive suicide risk screen.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs complete Focused Professional Practice Evaluations for all licensed independent practitioners.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete licensed independent practitioners’ professional practice evaluations.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in licensed independent practitioners’ professional practice evaluations.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs consider relevant Ongoing Professional Practice Evaluation data in reprivileging recommendations.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board uses professional practice evaluation results to recommend privileges for licensed independent practitioners.

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct environment of care inspections in patient care areas at the required frequency.

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures Automated External Defibrillator cabinets containing naloxone have alarms set in the “on” position, contain tamper-evident seals, display laminated “N” signs, and include naloxone inspection logs and administration reference cards.

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff check inventory in clean storerooms and remove expired supplies in the Emergency Department and medical/surgical inpatient unit.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Environmental Management Service maintains clean floors in the Dialysis Unit and medical/surgical inpatient unit clean storage and supply rooms.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff maintain safe and functional environments in the Dialysis Unit and medical/surgical inpatient unit.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff keep furnishings safe and in good repair in the intensive care and medical/surgical inpatient units.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff repair damaged walls in the Dental Clinic and Emergency Department.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff replace stained ceiling tiles in the Emergency Department and Primary Care Red Team.

The Medical Center Director determines any additional reasons for noncompliance and ensures staff post signage where recording equipment is used in the intensive care and medical/surgical inpatient units, Dental Clinic, and Primary Care Red Team indicating the areas are subject to photography, digital imaging, video, or audio recording.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers assess whether patients’ most recent suicide attempt was their most lethal when completing the Comprehensive Suicide Risk Evaluation.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Executive Committee of the Medical Staff recommends continuation of privileges based on Ongoing Professional Practice Evaluation results.

The Assistant Director for Efficiency and Improvement evaluates and determines any additional reasons for noncompliance and ensures managers comply with inpatient mental health unit environmental safety requirements.

The Chief Medical Officer determines any additional reasons for noncompliance and reviews the credentials files and recommends VA appointments for physicians with a history of licensure action.

The Network Director evaluates and determines additional reasons for noncompliance and submits a Comprehensive Environment of Care compliance report to the Environment of Care Committee annually.

The System Director determines any additional reasons for noncompliance and ensures the Chief of Staff conducts institutional disclosures for applicable sentinel events.

The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete adverse event investigations within seven days and document appropriately in the Joint Patient Safety Reporting system, or the Patient Safety Manager monitors the investigations until they are completed.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete the Ongoing Professional Practice Evaluations of licensed independent practitioners.

The System Director evaluates and determines any additional reasons for noncompliance and ensures managers keep areas used by patients clean, safe, and suitable for the care, treatment, and services provided.

The System Director determines any additional reasons for noncompliance and ensures staff monitor and document VA police response times to panic alarm testing in the Mental Health Inpatient Unit on a regular basis.

The Medical Center Director ensures the Peer Review Committee submits accurate peer review summary analysis data quarterly to the Health Care Delivery Council.

The Medical Center Director ensures the Health Care Delivery Council reviews the Peer Review Committee’s summary analysis quarterly and determines actionable items.

The Medical Center Director ensures employees comply with safe work practices to eliminate or minimize exposure to potentially infectious materials.

The Medical Center Director ensures the Inpatient Unit Nurse Manager for the medical/surgical intensive care unit restricts access to clean and sterile storerooms to authorized personnel.

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

The Medical Center Director ensures providers complete Comprehensive Suicide Risk Evaluations following patients’ positive suicide risk screens.