All Reports

The Under Secretary for Health ensures the Veterans Health Administration continues plans toward a sustainable workforce model, enterprise-wide image-sharing capabilities, and standardization of clinical workflows and workload distribution.

The Under Secretary for Health ensures that leaders at Veterans Health Administration facilities experiencing interruptions in radiology services (1) conduct comprehensive, proactive assessments of the clinical impact to patients awaiting completion of radiology studies; and (2) report any incidents of harm or potential harm from incomplete radiologic studies to facility quality management leaders for local tracking to reduce patient safety risks.

The VA Washington DC Healthcare System Director ensures that any incidents of harm or potential harm from incomplete radiologic studies are reported to facility quality management leaders for local tracking to reduce patient safety risks.

The Michael E. DeBakey VA Medical Center Director uses available resources to help recruit and hire an assistant chief of Sterile Processing Services.

The Michael E. DeBakey VA Medical Center Director, in conjunction with the chief of Sterile Processing Services, reviews reusable medical device inventory management and oversight processes to ensure compliance with Veterans Health Administration requirements, identifies deficiencies, and takes action as warranted.

The Michael E. DeBakey VA Medical Center Director reviews processes to track issue briefs related to surgery cancellations resulting from reusable medical device issues from initiation to closure, identifies deficiencies, and takes action as necessary.

Identify all relevant stakeholders and formally define roles and responsibilities for the police staffing decision tool or similar model.

Coordinate with all relevant stakeholders to address vulnerabilities with the police staffing decision tool or a similar model.

Ensure the Manpower Management Service’s standard operating procedures are followed to document formal completion of the police staffing decision tool or a similar model.

Assign accountability for disseminating the finalized police staffing decision tool or a similar model and ensuring its use.

Facility leaders direct staff to conduct a risk assessment on liquid nitrogen storage, to include the small devices stored in examination rooms, and implement changes if needed.

Facility leaders determine appropriate supply storage locations and, for any supplies stored outside of the defined locations, implement a process to ensure staff identify and remove expired supplies.

Facility leaders ensure staff label opened multidose medications with expiration dates.

Facility leaders ensure staff store clean and dirty items separately.

The Director ensures staff implement processes to prevent repeat environment of care findings.

The OIG recommends facility leaders ensure the facility has a policy for the communication of test results and staff develop service-level workflows that align with VHA requirements.

Veterans Integrated Service Network 19 leaders assess the staffing needs for the facility’s radiology service and provide additional resources to ensure services are readily available to patients.

Veterans Integrated Service Network 19 leaders evaluate the reasons for delays in uploading images and reporting test results and assist the facility’s community care leaders to mitigate future delays.

Executive leaders monitor root cause analysis improvement actions through completion, monitor outcome measures, and ensure staff implement processes to sustain the improvements.

Facility leaders attain appropriate primary care staffing and manageable panel sizes to ensure patients have timely access to high-quality care.

The Executive Director ensures staff receive education about badge holders’ responsibilities in preventing unauthorized access to VA facilities and computer systems and safeguarding electronic databases including electronic health care records.

The Executive Director ensures signs are present and accurate throughout the facility.

The Executive Director ensures staff maintain privacy curtains, preventive maintenance on medical equipment, and splash resistant bottom shelves on supply carts.

The Executive Director ensures staff monitor patient care areas for expired, damaged, and contaminated medications and remove them as needed.

The Executive Director ensures staff store medications in pharmaceutical grade refrigerators.

The Executive Director ensures primary care staffing is sufficient for patients to receive appropriate health care.

The Executive Director reviews staffing levels for the Housing and Urban Development–Veterans Affairs Supportive Housing program and takes action as needed.

The VA Nebraska—Western Iowa Health Care System Director ensures the installation of night lighting changes to accommodate patient comfort and facility staff’s ability to safely conduct rounding in applicable inpatient mental health unit patient rooms.

The VA Nebraska—Western Iowa Health Care System Director ensures establishment and implementation of guidance related to the facility inpatient mental health unit staff’s use and security of handheld flashlights to ensure appropriate education and training of handheld flashlights usage and storage.

The VA Nebraska—Western Iowa Health Care System Director establishes and ensures implementation of a patient safety observation rounds standard operating procedure consistent with Veterans Health Administration requirements.

The VA Nebraska—Western Iowa Health Care System Director reviews facility Mental Health Environment of Care Checklist processes related to development of mitigation plans as required by the Veterans Health Administration, and monitors compliance.

The VA Nebraska—Western Iowa Health Care System Director ensures compliance with Veterans Health Administration staffing requirements for areas identified as high-risk, such as the inpatient mental health unit, and monitors compliance.

The Under Secretary for Health evaluates the Veterans Health Administration written guidance for high-risk workplace staffing and determines if clarification is needed.

The VA Nebraska—Western Iowa Health Care System Director ensures staff that may provide coverage on the inpatient mental health unit receive applicable Prevention and Management of Disruptive Behavior training for high-risk units.

The VA Nebraska—Western Iowa Health Care System Director strengthens processes to ensure that supervisors are made aware of staff members that have not completed the applicable Prevention and Management of Disruptive Behavior training for high-risk units, to include the hands-on component, and monitors compliance.

The Under Secretary for Health considers written guidance regarding risk for violence assessment use in units identified as a high-risk workplace that can be used to temporarily change a unit’s acuity level and staffing needs.

The VA Nebraska—Western Iowa Health Care System Director reviews and ensures consistent application of facility nursing leaders’ use of risk for violence assessment on the inpatient mental health unit, and monitors for compliance.

The VA Nebraska—Western Iowa Health Care System Director evaluates the root cause analysis processes regarding reporting of action items and outcome measures in accordance with Veterans Health Administration requirements, takes action as needed, and monitors compliance.

The VA Nebraska—Western Iowa Health Care System Director evaluates processes requesting and reporting changes to authorized and operating beds on the inpatient mental health unit, takes action as needed, and monitors compliance.

The VA Midwest Health Care Network Director strengthens processes to ensure adequate oversight and adherence to Veterans Health Administration requirements pertaining to changes to authorized and operating inpatient mental health unit beds.

The New York/New Jersey VA Healthcare Network Director evaluates the circumstances that led to Network and Syracuse VA Medical Center leaders not following clinical restructuring requirements according to VHA Directive 1043.

The Syracuse VA Medical Center Director evaluates the implementation of high reliability organization principles when communicating changes to clinical operations that include stakeholders, service and section leaders, and staff input.

The Syracuse VA Medical Center Director evaluates facility contract processes and takes action to ensure leaders maintain adequate oversight of contracting milestones.

The Syracuse VA Medical Center Director evaluates the communication of established contingency plans and ensures alignment with high reliability organization principles.

The Syracuse VA Medical Center Director ensures the monitoring and evaluation of patient transfers according to Veterans Health Administration Directive 1094(1) and takes action as warranted.

The Syracuse VA Medical Center Director ensures annual procedural complexity designation infrastructure reviews are completed accurately and ensures administrative actions are performed as required.

The New York/New Jersey VA Healthcare Network Director evaluates fiscal year 2026 procedural complexity designation infrastructure reviews for all Veterans Integrated Service New York/New Jersey VA Health Care Network facilities and takes action to ensure reviews are accurate and deficiencies are addressed as required.

The Under Secretary for Health ensures a timeliness expectation for infrastructure waiver submissions pursuant to Veterans Health Administration Directive 1220(1).

Enforce procedures for Veterans Health Administration human resources officials to monitor employee service obligations and initiate a debt notice when an employee breaches that agreement, if warranted.

Identify and review active incentives of Veterans Health Administration employees who transferred within or left VA and take action, if appropriate.

Establish enhanced internal controls to ensure compliance with the law on recruitment, relocation, and retention incentives and take appropriate action when an employee with an active service obligation transfers within the Veterans Health Administration.

Complete the evaluation of the incentives awarded to the employees identified in this report who may not have fulfilled their service obligations, determine whether a debt was incurred, and take any appropriate action.

The Director, National Teleradiology Program ensures guidance in memoranda of understanding, teleradiology service agreements, and policies related to the entity responsible for the completion of National Teleradiology Program radiologist peer reviews is consistent and aligns with Veterans Health Administration requirements.

The Director, National Teleradiology Program reviews the barriers, to include staffing shortages, to achieving turnaround time goals and creates a plan of action to optimize results.

The Director, National Teleradiology Program, in cooperation with Veterans Health Administration’s National Radiology Program, explores additional options for the recruitment and retention of National Teleradiology Program radiologists.

The Under Secretary for Health, in cooperation with Veterans Health Administration’s National Radiology Program, reviews the tools available for the recruitment and retention of radiologists across the Veterans Health Administration and creates a plan of action to optimize filling vacant positions.

The Under Secretary for Health ensures all facilities with an agreement for service by the National Teleradiology Program have a contingency plan.