All Reports

The Central Virginia VA Health Care System Director evaluates inpatient mental health unit discharge practices and develops processes to assess a caregiver’s capability to ensure a safe discharge.

The Central Virginia VA Health Care System Director ensures complaints to the patient advocate are reviewed and addressed in accordance with Veterans Health Administration Directive 1003.04, VHA Patient Advocacy.

The Central Virginia VA Health Care System Director ensures medication reconciliation is completed at discharge and during post-discharge encounters according to Veterans Health Administration Directive 1345, Medication Reconciliation.

The Central Virginia VA Health Care System Director ensures compliance with Veterans Health Administration Directive 1199, Reporting Cases of Abuse and Neglect, requirements related to clinical staff escalating encounters involving potential abuse and neglect.

The Central Virginia VA Health Care System Director conducts a comprehensive review of the patient’s hospitalization and post-discharge encounters and takes action as indicated, including quality management improvement processes.

The Under Secretary for Health considers establishing a process, to be used on non‑business days, that enables Veterans Crisis Line responders to timely escalate concerns of non‑imminent abuse to a mandated reporter.

The Under Secretary for Health reviews Veterans Health Administration’s compliance with requirements for postpartum care coordination contacts by the maternity care coordinator and implements an action plan to ensure sustained compliance.

The Under Secretary for Health reviews Veterans Health Administration maternity care coordinators’ compliance with requirements for postpartum screenings and implements an action plan to ensure sustained compliance.

The Under Secretary for Health evaluates concerns regarding community care billing and billing resolution processes for maternity care and implements an action plan as warranted.

The Under Secretary for Health evaluates the scheduling and completion of postpartum primary care appointments within three months of delivery and implements an action plan to ensure sustained compliance.

The VA Portland Health Care System Director ensures the Community Reintegration Services director and Health Care for Homeless Veterans program coordinator establish a process to monitor and verify case managers comply with monthly veteran contacts as required by the facility’s HCHV Case Management Workflow Guide, and takes action as warranted.

The VA Portland Health Care System Director ensures Health Care for Homeless Veterans staff discharge veterans from the Health Care for Homeless Veterans program in accordance with the facility’s HCHV Case Management Workflow Guide.

The VA Portland Health Care System Director reviews the quality management evaluations, once completed, for Veteran A’s and Veteran B’s care, and takes action as warranted.

The VA Portland Health Care System Director evaluates the Community Reintegration Services reporting structure and resources to determine if the current structure allows for effective oversight of essential homeless programs, and makes modifications if needed.

The VA Portland Health Care System Director ensures the Community Reintegration Services director monitors and verifies Grant and Per Diem liaisons’ compliance with Veterans Health Administration Directive 1162.01 requirements related to conducting veteran contacts.

The Under Secretary for Health reviews the comprehensive traumatic brain injury evaluation referral process for veterans with positive traumatic brain injury screens and ensures veterans interested in further evaluation are referred for a comprehensive traumatic brain injury evaluation.

The Under Secretary for Health considers the development of a uniform referral method for the utilization of Polytrauma System of Care resources.

The Under Secretary for Health reviews the one-time use limitation of the comprehensive traumatic brain injury evaluation template to allow documentation of additional evaluations whenever a veteran screens positive for deployment-related traumatic brain injury after a subsequent separation.

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 Veterans Integrated Service Network 7 VA Southeast Network Director ensures relevant system staff and leaders are trained on state licensing board reporting requirements to include timeliness of reporting.

The Veterans Integrated Service Network Director ensures actions are completed to address findings from the electronic health record audit expected to be completed by June 2026 and the annual site visit(s) of the Eastern Oklahoma VA Health Care System homemaker/home health aide program.

The Veterans Health Administration Executive Director of Geriatrics and Extended Care, in collaboration with the Veterans Health Administration Geriatrics and Extended Care program manager, provides guidance for Veterans Integrated Service Network and Veterans Health Administration systems’ leaders to evaluate homemaker/home health aide programs in accordance with the Veterans Health Administration Office of Integrated Veteran Care Community Care Field Guidebook and Veterans Health Administration Notice 2024-01, Purchased Home and Community-Based Services.

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.

The Martinsburg VA Medical Center Director conducts a comprehensive review of the peer review process from identification to completion to ensure adherence with Veterans Health Administration Directive 1190(1), Peer Review for Quality Management, amended July 19, 2024, and takes action as warranted.

The Martinsburg VA Medical Center Director ensures the chief of surgery assesses Surgeon B’s alleged disruptive behavior and takes action if needed, in accordance with VA Handbook 5021, Employee-Management Relations, and Martinsburg VA Medical Center bylaws.

The Veterans Integrated Service Network Director conducts a comprehensive review of the care provided to the patient prior to the event, and takes action as indicated.

The Robley Rex VA Medical Center Director ensures that the facility has a mechanism in place for how Veterans Health Administration healthcare professionals will provide content of suicide prevention safety plans when completing suicide prevention safety plans with patients over the phone.

The Robley Rex VA Medical Center Director reviews facility Primary Care-Mental Health Integration guidance documents and ensures consistency and alignment with Veterans Health Administration requirements.

The Robley Rex VA Medical Center Director reconsiders the practice of reauthoring notes in the Computerized Patient Record System by behavioral health technicians in the Primary Care-Mental Health Integration call center, identifies other facility areas that use the reauthoring process, and takes action as indicated.

The Under Secretary for Health evaluates ways to mitigate the implications resulting from users’ ability to change authors in an unsigned note in the Computerized Patient Record System to ensure that such practice is limited to those in roles with a need to have that function, and takes action as indicated.

The Robley Rex VA Medical Center Director ensures that root cause analyses are completed in accordance with Veterans Health Administration policy, including root cause analysis process steps, timeliness, and team roles.

The Robley Rex VA Medical Center Director ensures that patient safety managers receive oversight, training, and support as required by the Veterans Health Administration.

The Robley Rex VA Medical Center Director ensures that the chief of quality understands the seriousness and implications of altering documentation without support, and that leaders, whose actions contributed to the deficiencies outlined in this report, receive administrative action, as appropriate.

The VA Caribbean Healthcare System Director ensures that facility leaders make decisions regarding the need for institutional disclosures independent of the peer review process in alignment with VHA Directive 1190 (1), Peer Review for Quality Management.

The West Palm Beach VA Healthcare System Director ensures 3C leaders are aware of and comply with Mental Health Environment of Care Checklist requirements on the inpatient mental health unit.

The West Palm Beach VA Healthcare System Director reviews the inpatient mental health patient safety observation practices to ensure compliance with VHA SOP 1160.06.1, “Standard Operating Procedure for Maintaining Safety and Security on Inpatient Mental Health Units Under VHA Directive 1160.06,” and Facility Medical Center Policy 118-01, Enhanced Observation Level requirements.

The West Palm Beach VA Healthcare System Director ensures staff performing patient safety observation on 3C receive recurring training on conducting observation practices, including face-to-face visualization, in alignment with VHA SOP 1160.06.1, “Standard Operating Procedure for Maintaining Safety and Security on Inpatient Mental Health Units Under VHA Directive 1160.06,” requirements.

The West Palm Beach VA Healthcare System Director develops and implements an oversight process for ongoing monitoring of inpatient mental health patient safety observation practices and documentation to ensure compliance with VHA SOP 1160.06.1, “Standard Operating Procedure for Maintaining Safety and Security on Inpatient Mental Health Units Under VHA Directive 1160.06” requirements.

The West Palm Beach VA Healthcare System Director develops a plan to reassess the effectiveness of the oversight process.

The West Palm Beach VA Healthcare System Director ensures that when 3C leaders identify incongruencies between patient safety observation practice and documentation, 3C leaders conduct a review of the incident and take corrective action, as warranted.

The Under Secretary for Health ensures the third-party administrator and community care breast imaging providers are informed of the expectations and processes for provision of breast images to the referring VA facility, addresses any barriers identified, and follows up to ensure compliance.

The VA Eastern Colorado Health Care System Director ensures that facility community care staff comply with Veterans Health Administration requirements for requesting medical records, including images, from community providers and documentation of the receipt of medical records, including images, and follows up to ensure compliance.

The VA Eastern Colorado Health Care System Director reviews processes, to ensure community care images are uploaded timely; assesses identified barriers, including staffing; and follows up to ensure compliance.

The Under Secretary for Health reviews limitations of current VA image sharing technologies, considers implementation of technologies to support timely sharing of images with community providers, and takes action as warranted.

The VA Eastern Colorado Health Care System Director reviews facility policy and standard operating procedures to ensure sufficient guidance and resources for compliance with Veterans Health Administration requirements for breast cancer screening, follow-up, and care coordination, and takes action as warranted.

The VA Eastern Colorado Health Care System Director assesses the scope of the lack of tracking of breast cancer screening and follow-up for patients with a BIRADS 0, 3, 4, 5, or 6 from at least February 2024 forward to ensure all patients receive appropriate notification and timely follow-up of findings, and takes action as indicated.

The VA Eastern Colorado Health Care System Director ensures credentialing and privileging staff complete primary source verification of credentials, and monitors for compliance.

The VA Eastern Colorado Health Care System Director makes certain that clinical service chiefs follow processes for review of supporting documentation during the credentialing and privileging process, and follows up to ensure compliance.

The VA Eastern Colorado Health Care System Director ensures that the radiology service chief initiates focused professional practice evaluations timely, as required, and monitors for compliance.

The VA Loma Linda Healthcare System Director ensures the Chief of Staff signs peer review designation memoranda within three days of determining a peer review is needed as outlined in Veterans Health Administration policy.

The VA Loma Linda Healthcare System Director ensures that focused professional practice evaluations for initial appointments and additional privileges are completed in accordance with Veterans Health Administration policy and monitors for compliance.

The VA Fayetteville Coastal Healthcare System Director confirms full implementation of the VA Community Care Oversight and Consult Management Council.

The Under Secretary for Health reviews practices and procedures for managing consults to identify and prioritize appointment scheduling for patients with serious health conditions (high‑priority consults), such as cancer, and provide direction to the field on the process to use to make this determination.

The VA Fayetteville Coastal Healthcare System Director directs the development and implementation of community care service standard operating procedures to address identification and management of high-priority consults, timeliness of consult processing, and care coordination that aligns with direction provided by Veterans Health Administration’s Integrated Veterans Care program.

The VA Fayetteville Coastal Healthcare System Director ensures staff are trained in all newly developed community care standard operating procedures and that adherence to policy and practice is monitored.

The VA Fayetteville Coastal Healthcare System Director confirms completion of a review of quality management processes to ensure quality management staff, when reviewing patient safety events, consider potential system issues and, if present, recommend they be addressed using other quality management reviews.

The VA Fayetteville Coastal Healthcare System Director ensures local processes are in place, including assigned roles and responsibilities, to manage Office of Inspector General case referrals in compliance with VA Directive 0701, Office of Inspector General Hotline Complaint Referrals.

The VA Fayetteville Coastal Healthcare System Director confirms reasonable efforts to conduct an institutional disclosure with the patient regarding circumstances that led to the delay in the diagnosis of and treatment for lung cancer are made and, if a disclosure is completed, that it is documented in the electronic health record.

The Under Secretary for Health assesses the electronic health record reviews completed by the system in response to the community care backlog to determine if a more comprehensive review is warranted with appropriate disclosure to patients placed at risk or harmed as a result of a delay in action on their community care consult, and takes action accordingly.

The Richard L. Roudebush VA Medical Center Director establishes a process to ensure that changes impacting the availability of clinical services to patients are clearly communicated to all relevant staff members.

The Richard L. Roudebush VA Medical Center Director ensures that residents, fellows, and clinical service leaders understand and follow the requirement to document complete and pertinent information, including assessments and recommendations, in patients’ electronic health records.

The Richard L. Roudebush VA Medical Center Director educates providers on the requirements related to completing a clinical disclosure when an adverse event occurs, such as a delay in care.

The Richard L. Roudebush VA Medical Center Director ensures the episode of care related to the patient’s transfer is reviewed to determine whether an institutional disclosure is needed in accordance with Veterans Health Administration requirements, and takes action as warranted.

The Richard L. Roudebush VA Medical Center Director monitors to ensure that Joint Patient Safety Reporting system reports are included or rejected in accordance with Veterans Health Administration guidance.

The Richard L. Roudebush VA Medical Center Director ensures a comprehensive review of the patient’s care and transfer is completed to identify factors that contributed to the patient’s unnecessary transfer and takes action as warranted.

The Oklahoma City VA Health Care System Director, with Pathology and Laboratory Medicine Service leaders, conducts a comprehensive review of the quality of care for the four patients identified in this report, including determinations of cytopathology processing delays and assessment of patient harm, and takes action as warranted.

The Oklahoma City VA Health Care System Director ensures that routine non-gynecological turnaround time corrective actions are documented and monitored for effectiveness, as required by the Veterans Health Administration.

The Oklahoma City VA Health Care System Director conducts a comprehensive review of the quality of care provided by the Chief of Pathology and Laboratory Medicine Service, identifies deficiencies, and takes action as warranted. 

The Oklahoma City VA Health Care System Director reviews the Pathology and Laboratory Medicine Service event reporting requirements for variance events and ensures completion according to facility policy and Veterans Health Administration requirements.

The Oklahoma City VA Health Care System Director, in conjunction with the National Center for Patient Safety, evaluates patient safety event reporting processes within the Pathology and Laboratory Medicine Service, and ensures completion according to Veterans Health Administration requirements.

The Veterans Integrated Service Network Director develops and implements a plan to provide sustained support and oversight in a constructive manner to the VA Dublin Healthcare System leaders and programs.

The Veterans Integrated Service Network Director ensures that following Veterans Integrated Service Network site reviews with findings, Veterans Integrated Service Network staff review the associated VA Dublin Healthcare System action plans to confirm proposed actions adequately address findings, track action items through implementation, evaluate effectiveness to ensure resolution, and monitor for sustainment.

The Under Secretary for Health considers standardizing the Veterans Integrated Service Network Chief Medical Officer’s and Chief Nursing Officer’s role and responsibilities to include the authority to hold systems leaders accountable for resolving identified deficiencies.

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.