All Reports

The Director takes appropriate action for employees to keep patient care areas clean as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program and clean storerooms as required by Veterans Health Administration Directive 1761, Supply Chain Management Operations.

The Director takes appropriate action for employees to inspect and test all medical equipment as required by The Joint Commission standard PE [Physical Environment] 04.01.01.

The Director takes appropriate action so pharmaceutical waste containers are provided and accessible, and trains employees on container use as required by Veterans Health Administration Directive 1850.06(1), Waste Management Program.

The Director takes appropriate action so employees secure power strips as required by National Fire Protection Association’s Health Care Facilities Code, NFPA 99 and electrical cords are connected to prevent pulling or straining as required by National Electrical Code, NFPA 70.

Facility leaders take appropriate actions so staff maintain a safe and clean environment, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Chief of Staff and Associate Director for Patient and Nursing Services develop service-level workflows that outline responsibilities in the patient notification process and update the facility’s test result communication policy to align with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient and Nursing Services implement actions based on external peer review data to improve providers’ communication of test results to patients, in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions so that staff consistently follow the facility’s Legionella prevention plan and achieve and sustain compliance with all applicable requirements in Veterans Health Administration Directive 1061(4), Prevention of Health Care-Associated Legionella Disease and Scald Injury from Water Systems to prevent contamination and maintain water quality, including testing, documentation, and mitigation actions, to protect resident safety in the community living center.

The Director develops and implements a written policy for communicating test results that aligns with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services develop written service-level workflows that align with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services take corrective actions to address unfavorable trends in the communication of test results in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director evaluates the Healthcare Delivery Board and takes actions when warranted to provide proper oversight of clinical care quality in accordance with Joint Commission standards Medical Staff 16.01.01 and Leadership 11.01.01.

The Chief of Staff and Associate Director for Patient Care Services take appropriate actions to develop written service-level workflows that describe team members’ roles in the process of communicating test results, per Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services review performance measure data for test result communications and take corrective action when they identify noncompliance with communicating abnormal test results within seven days, per Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director performs a comprehensive safety risk assessment of enclosed walkways and implements necessary corrective actions to mitigate slip hazards, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate actions for staff to regularly identify and remove expired supplies in all areas outside standard supply rooms to comply with Veterans Health Administration Directive 1761, Supply Chain Management Operations.

The Veterans Integrated Service Network Director monitors the facility’s processes to prevent repeat environment of care findings and takes any needed actions to meet the requirements of Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate actions so leaders update the facility’s policy for communicating test results to include how providers communicate life-changing results to patients at high risk for suicide, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services develop workflows that describe how each team member participates in the process to communicate test results, in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate action so staff update the facility’s test result communication policy to align with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services develop workflows that describe staff members’ roles in the process of communicating test results to providers and patients, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate action so staff conduct a risk assessment to identify areas that need temperature and humidity monitoring and implement changes accordingly to comply with Veterans Health Administration Directive 1761, Supply Chain Management Operations.

The Director takes appropriate action so staff secure liquid nitrogen tanks, maintain unobstructed access to exits, conduct a risk assessment on safe liquid nitrogen storage options to increase safety, and implement changes accordingly to align with the National Fire Protection Association’s Compressed Gases and Cryogenic Fluids Code NFPA 55, Health Care Facilities Code NFPA 99, and Code of Federal Regulations title 29, section 1926.34.

The Director takes appropriate action so staff improve processes to prevent repeat environment of care findings as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate action so leaders update their local policy and develop service-level workflows for test result communications, in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions to strengthen staff accountability for maintaining clean and safe patient care areas as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate actions so staff validate and document airflow testing in supply rooms annually as required by Veterans Health Administration Directive 1761, Supply Chain Management Operations.

The Director takes appropriate actions so staff conduct a risk assessment to identify areas that require temperature and humidity monitoring and implement changes as required by Veterans Health Administration Directive 1761, Supply Chain Management Operations and Veterans Health Administration Directive 1108.07(2), General Pharmacy Service Requirements.

The Director implements controls so staff repair or replace malfunctioning fire doors to ensure proper closure during emergencies as required by the National Fire Protection Association’s Standard for Fire Doors and Other Opening Protectives, NFPA 80.

The Director implements measures so staff conduct all required fire safety inspections and document the results as required by the National Fire Protection Association’s Standard for Fire Doors and Other Opening Protectives, NFPA 80.

The Director takes appropriate actions to implement measures to test sprinkler systems as required by the National Fire Protection Association’s Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, NFPA 25.

The Director takes appropriate actions so staff evaluate processes to prevent repeat environment of care findings and take actions as warranted.

The Veterans Integrated Service Network Director monitors for similar or repeat environment of care findings and takes appropriate actions so facility leaders develop and implement facility-wide corrective action plans and sustain improvements.

The Director takes appropriate actions so each service chief develops a workflow that describes staff members’ roles in the process of communicating test results to providers and patients as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions so staff track root cause analysis–driven improvement actions through to completion, monitor outcome measures, and implement processes to sustain improvements to comply with Veterans Health Administration National Center for Patient Safety’s Guide to Performing Root Cause Analysis.

The Chief of Staff takes appropriate action for evaluation and improvement of processes to identify adverse events that warrant institutional disclosures to patients or their representatives as required by Veterans Health Administration Directive 1004.08, Disclosure of Adverse Events to Patients.

The Medical Center Director takes appropriate action so emergency department and dental clinic staff maintain a clean and safe environment and repair or replace damaged items to support effective disinfection, as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Medical Center Director takes appropriate action so emergency department staff establish and maintain an environment that protects patients’ privacy, as required by the Joint Commission standard, Rights and Responsibilities of the Individual 01.01.01.

The Medical Center Director takes appropriate action so all services develop workflows in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients, including defining responsibilities of non-provider personnel for communicating test results to patients.

The Director installs detectable warning surfaces at all walkways that transition to roadways, in accordance with VA’s PG-18-10, Site Design Manual.

The Director takes appropriate action so staff update the facility policy for communicating test results and develop service-level workflows that describe team members’ roles in the process, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Veterans Integrated Service Network Director and facility Director take appropriate action for the surveillance system to be fully operational.

The Director takes appropriate actions to secure portable liquid nitrogen tanks and store the tanks according to the National Fire Protection Association’s Compressed Gases and Cryogenic Fluids Code, NFPA 55 requirements.

The Wm. Jennings Bryan Dorn VA Medical Center Director ensures that all patients admitted to the intensive care unit receive access to continuous critical care, particularly after hours, and clearly defines the role and responsibilities of the on-site intensivist and TeleCritical Care in the care of surgical intensive care unit admissions.

The Wm. Jennings Bryan Dorn VA Medical Center Director ensures that in the absence of patient-specific orders for vital sign parameters that warrant provider notification, intensive care unit nurses adhere to facility policy for provider notification parameters.

The Wm. Jennings Bryan Dorn VA Medical Center Director reviews VHA Directive 1155(1), Treatment of Acute Ischemic Stroke, August 22, 2025, and ensures the facility is in full compliance with current stroke center designation requirements, including protocols for inpatient stroke response, diagnostic imaging, consultation, and transfer processes.

The Wm. Jennings Bryan Dorn VA Medical Center Director clarifies the qualifications for provider coverage in the intensive care unit and ensures all intensive care unit providers are appropriately privileged to deliver care in the intensive care unit prior to providing care.

The Wm. Jennings Bryan Dorn VA Medical Center Director determines whether providers delivered patient care in the intensive care unit without approved, current, facility‑specific privileges and, if so, completes required reviews and assessments in accordance with VHA requirements.

The Wm. Jennings Bryan Dorn VA Medical Center Director creates a process ensuring contract ICU physicians covering in the intensive care unit have access to the electronic health record for documentation and order writing from the start of their tour.

The Wm. Jennings Bryan Dorn VA Medical Center Director reviews this patient’s case and any associated quality management reviews, and if gaps are identified, develops an action plan to ensure quality management processes are completed in accordance with relevant VHA quality management directives.

Facility leaders take appropriate actions so staff develop a written workflow for each service that is consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.