All Reports

The Assistant Under Secretary for Health for Quality and Patient Safety establishes facility patient safety program oversight requirements for patient safety officers to include minimum frequency and volume of oversight activities and expectations for follow-up when patient safety program deficiencies are identified.

The National Center for Patient Safety Executive Director evaluates the National Center for Patient Safety quarterly reports, includes an analysis of patient safety data in the reports, and establishes a mechanism for National Center for Patient Safety, in conjunction with Veteran Integrated Service Networks, to direct interventions to promote improvements when facility patient safety program requirements are not met or if deemed necessary to enhance patient safety programs.

The Under Secretary for Health evaluates barriers to communication between third-party administrators and patient safety officers and takes action as needed to resolve barriers.

The Assistant Under Secretary for Health for Quality and Patient Safety evaluates barriers that limit engagement between Veteran Integrated Service Network and facility directors and patient safety officers and patient safety managers.

The National Center for Patient Safety Executive Director develops a patient safety program staffing configuration for patient safety managers to include facility complexity and patient safety program requirements with recurring reassessment and revision based on requirement changes.

The National Center for Patient Safety Executive Director establishes staffing guidance for Veteran Integrated Service Network patient safety programs to include facility complexity and workload from other assigned responsibilities to ensure prioritization of patient safety officer oversight and support of facility patient safety programs.

The National Center for Patient Safety Executive Director establishes processes to evaluate factors contributing to patient safety managers and patient safety officers’ burnout, including patient safety manager turnover, and implements actions as needed to address burnout.

The National Center for Patient Safety Executive Director evaluates patient safety manager and patient safety officer training and implements standardized formalized training with requirements for newly appointed patient safety managers and newly appointed patient safety officers to include time frames and completion.

The National Center for Patient Safety Executive Director establishes standardized continuing education requirements to meet the training needs for patient safety managers and patient safety officers.

Improve vulnerability management processes to ensure system changes occur within organization timelines.

Develop and approve an authorization to operate for the special-purpose systems.

Include system personnel during the security categorization process to ensure that all necessary information types are considered when determining the security categorization for special-purpose systems.

Implement the appropriate physical security controls to restrict and monitor access to the facility, its server room, communication closets, and generators.

Implement and monitor emergency power and uninterruptible power supplies that support information technology resources.

Validate that appropriate physical and environmental security measures are implemented and functioning as intended.

The assistant secretary for information technology develop a timeline for updating the security and privacy guidance to reflect the latest revisions to the National Institute of Standards and Technology Special Publication 800-53, Security and Privacy Controls for Federal Information Systems and Organizations, and address identified weaknesses with personally identifiable information and supply chain management.

The assistant secretary for information technology eEstablish a mechanism to ensure continuous monitoring of VA Enterprise Cloud systems to include having and testing contingency, incident response, and disaster recovery plans and conducting scanning as required.

The assistant secretary for information and technology continue to improve criteria and processes for submitting claims for recoupment of service credits.

The assistant secretary for information and technology assign roles and responsibilities for submitting claims for service credits and monitoring outcomes.

Implement a more effective vulnerability management program to address security deficiencies identified during the inspection.

Ensure vulnerabilities are remediated within OIT’s established time frames.

Ensure physical access controls are implemented for communication rooms.

Ensure communication rooms with infrastructure equipment have adequate environmental controls.

Test the emergency power bypass during annual uninterruptible power supply testing and document results.

Clarify roles and responsibilities of the Office of Integrated Veteran Care and third-party administrators with respect to ensuring non-VA providers receive and certify they have reviewed Opioid Safety Initiative guidelines in accordance with the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 and collaborate with the contracting office to modify the contracts as appropriate.

Ensure the Office of Integrated Veteran Care strengthens controls to monitor the third-party administrators to ensure non-VA providers’ completion of the VA Opioid Safety Initiative training module.

Ensure the Office of Integrated Veteran Care strengthens controls to monitor the third-party administrators to ensure non-VA providers’ completion of required prescription drug monitoring program queries

Ensure that Veterans Health Administration fiscal staff are trained on VA financial policy requirements for the preparation and approval of journal vouchers (including expenditure transfers).

Develop and implement procedures to ensure the Veteran Readiness and Employment Service has properly researched and clearly understands changes to the laws and regulations that govern Chapter 31–only schools and training programs.

Review the existing manual requirements for waivers and coordinate with appropriate officials to ensure amendments to 38 United States Code § 3104(b) have been properly implemented and included in the manual.

Train all appropriate Veteran Readiness and Employment Service regional office staff to ensure waivers are obtained for each veteran with the required documentation in accordance with the manual before approval to attend a Chapter 31–only school or training program.

Coordinate with appropriate officials to determine whether the existing manual guidance for compliance surveys meets the requirements of 38 United States Code § 3693 as it applies to Chapter 31–only schools and training programs, and if necessary, update the manual and train appropriate Veteran Readiness and Employment Service regional office staff accordingly.

Develop and implement monitoring processes—to include veteran waivers, compliance surveys, and completeness of electronic folders—to provide Veteran Readiness and Employment Service reasonable assurance that Chapter 31–only schools and training programs are used as intended by law and regulations.

The Veterans Crisis Line Director conducts a full review of the Veterans Crisis Line staff’s management of the patient and third-party contacts, consults with Human Resources and General Counsel Offices, and takes actions as warranted.

The Veterans Crisis Line Director expedites the alignment of the Medora documentation template with the VA and Department of Defense Clinical Practice Guideline and Veterans Crisis Line guidelines for suicide risk assessment classification levels.

The Veterans Crisis Line Director ensures and strengthens the quality management oversight of staff who provide crisis management services, including overtime coverage.

The Veterans Crisis Line Director confirms the retention of crisis management text conversations and establishes supervisory oversight protocols.

The Veterans Crisis Line Director ensures issue briefs accurately reflect the action plan.

The Veterans Crisis Line Director identifies criteria for immediate internal reviews of customers’ deaths by suicide and accidental overdose to identify crisis management and administrative performance improvement actions.

The Veterans Crisis Line Director conducts a full review of the patient’s text contact, determines whether an institutional disclosure is warranted, and takes action as indicated.

The Veterans Crisis Line Director monitors compliance with the submission and oversight of notification of a customer’s death, including timely submission of a suicide prevention coordinator consult.

The Veterans Crisis Line Director conducts a review of the interactions between the Director, Quality and Training, and staff in preparation and during the Office of Inspector General healthcare inspection, educates staff on the importance of fully cooperating, responding in an open and transparent manner, and avoiding any appearance of coordination between employees, and take actions as warranted.

The Veterans Crisis Line Director clarifies and strengthens procedures for complaint submission, provides staff training, ensures consistency with the Veterans Health Administration directive, and monitors compliance.

The South Texas Veterans Health Care System Director ensures that processes are established for timely death notification entry in patients’ electronic health records.

The South Texas Veterans Health Care System Director ensures that staff adheres to the January 2022 standard operating procedures for administrative and clinical actions following a patient’s or employee’s death by suicide.

The Veterans Crisis Line Director strengthens processes to ensure discontinuation of caring letters in a timely manner following notification of a patient’s death.

The South Texas Veterans Health Care System Director makes certain that the Suicide Prevention Program ensures full implementation of the Behavioral Health Autopsy Program as required by the Veterans Health Administration.

Conduct national refresher training on the Electronic Health Record Modernization National Process Memorandum and assess training effectiveness

Consider updating VA Manual 21-4 to reflect that quality assurance measures include addressing failures to consider all Veterans Health Administration records as directed in the Adjudication Procedures Manual that are subject to an enterprise-wide search in the Compensation and Pension Records Interchange system whether or not directed to those records by the claimant and ensure staff are advised of the changes.

The Pension and Fiduciary Service clarifies procedural requirements to fiduciary hub staff on how to verify whether VA-derived funds of deceased beneficiaries must be returned to VA, including whether the fiduciary identified any valid will or heir to whom the funds are otherwise due.

The Pension and Fiduciary Service identifies existing or implements new electronic controls that allow VBA staff to track Fiduciary Program tasks, timeliness, and workload related to the return of deceased beneficiaries’ VA-derived funds to VA that would otherwise escheat to a state if not disbursed to heirs.

The Pension and Fiduciary Service and the Office of Field Operations establish a methodology and monitor workload to ensure the prompt return of deceased beneficiaries’ VA-derived funds.

The Under Secretary for Health reviews the operational memorandum for lung cancer screening implementation and assesses whether lung cancer screening rates could be enhanced by allowing a facility to conduct lung cancer screening while developing all mandated elements.

The Under Secretary for Health reviews the operational memorandum for lung cancer screening implementation and assesses whether lung cancer screening rates could be enhanced by reevaluating, prioritizing, and clarifying the mandated elements.

The Under Secretary for Health considers mandating eligible patients be offered lung cancer screening consistent with other required cancer screening in the Veterans Health Administration.

Implement consistent data entry, standardized organizational codes, and periodic reviews for HR Smart community care data.

Develop staffing reports that can be searched by service departments to ensure appropriate resources to meet their assigned missions.

Improve usability of the staffing assessment tool by implementing policy to address the inconsistencies with staffing data entry and review the reported data for accuracy.

Assess whether consolidated community care units would more broadly support veterans’ access to community care and help mitigate the impact of staffing shortages, and, if so, develop a project management plan for implementing those units.

Assess the use of monetary and nonmonetary incentives to evaluate whether they are effective in recruiting and retaining administrative staff within community care departments.

Implement a more effective vulnerability management program to address security deficiencies identified during the inspection.

Ensure vulnerabilities are remediated within established time frames.

Implement an improved inventory process to ensure that all connected devices used to support VA programs and operations are documented in the Enterprise Mission Assurance Support Service.

Ensure network infrastructure equipment is properly installed.

Ensure physical access controls are implemented for communication rooms.

Ensure a video surveillance system is operational and monitored for the data center.

Ensure communication rooms with infrastructure equipment have fire-detection and suppression systems.

Ensure water detection sensors are implemented in the data center.

The Under Secretary for Health directs the Office of Primary Care and Office of Mental Health and Suicide Prevention to identify barriers to provider documentation of opioid use disorder in progress notes and implement solutions addressing these barriers.

The Under Secretary for Health ensures the Office of Primary Care and Office of Mental Health and Suicide Prevention determine impediments to maintaining accurate identification of opioid use disorder in electronic health record problem lists and implement policy and training to support accurate use of problem lists.

The Under Secretary for Health confirms the Office of Primary Care and Office of Mental Health and Suicide Prevention evaluate barriers affecting provider access and use of Department of Defense treatment records in Joint Longitudinal Viewer and implement solutions.

The Under Secretary for Health ensures the Office of Primary Care and Office of Mental Health and Suicide Prevention improve continuity of care by confirming providers are educated on the navigation and retrieval of Department of Defense treatment records in Joint Longitudinal Viewer.

The Under Secretary for Health requires the Assistant Under Secretary for Health for Clinical Services/Chief Medical Officer to evaluate and update processes for identification of veterans with a history of opioid use disorder for the provision of opioid overdose risk mitigation strategies.