All Reports

The Chief of Staff and Associate Director for Patient Care Services develop workflows that describe how each team member participates in the process for communicating test results.

The Associate Director keeps patient care areas clean and stores dirty and clean items separately.

The Medical Center Director develops service-level workflows for communicating test results.

The Medical Center Director monitors data on the communication of test results to providers and patients as required by VHA Directive 1088(1), Communicating Test Results to Providers and Patients.

Facility leaders ensure staff follow procedures to properly separate and store soiled and clean equipment.

Facility leaders ensure environmental management services staff clean ice machines daily to help prevent infection risk.

Facility leaders ensure staff properly label and store oxygen tanks.

Facility leaders ensure staff update the facility policy to include all elements to communicate test results to patients, as required in Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

Executive leaders ensure staff maintain a clean and safe environment.

The Medical Center Director ensures providers complete secondary toxic exposure screenings within 30 days.

The Chief of Staff ensures facility leaders develop workflows for all services to identify team members’ roles in the process for communicating test results.

The Director ensures Environmental Management Services staff keep patient care areas clean and well maintained.

Facility leaders ensure staff place signs on or near each building to help veterans easily navigate where services are located.

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 Executive Medical Center Director ensures clinical staff can open all doors to shared bathrooms.

The Executive Medical Center Director ensures staff keep exterior doors closed to minimize risk to wandering patients.

The Executive Medical Center Director ensures staff store clean and dirty equipment and supplies separately.

The Executive Medical Center Director ensures each service has workflows to communicate test results.

Facility leaders ensure the community living center’s dementia unit shower room is clean and free from hazards, and that leaders conduct a risk assessment to determine the need for other safety measures.

The Medical Center Director ensures facility staff conduct a privacy assessment and take actions to protect patient information in the Emergency Department.

Facility leaders ensure all eyewash stations are clean and function properly.

The Medical Center Director ensures the facility has a written policy for communication of test results.

The Chief of Staff and Associate Director of Patient Care Services ensure leaders in each service develop written service-level workflows that outline the process for staff to communicate test results to providers and patients.

The Veterans Integrated Service Network Director ensures executive leaders implement a process to monitor actions related to Veterans Health Administration policy changes.

The Medical Center Director ensures the Chief of Staff and Associate Director of Patient Care Services review performance metrics for test result communications and take action for identified deficiencies.

The Medical Center Director ensures executive leaders attend Quality and Patient Safety Council meetings.