All Reports

The Ann Arbor VA Medical Center Director conducts a full review of the patient’s spring to fall 2017 mental health care to identify quality of care improvement opportunities related to inpatient psychiatrist 2’s medical decision-making, staff’s pre-discharge outpatient care planning, and outpatient staff’s collaboration in providing treatment and engagement efforts including the mental health treatment coordinator assignment and role, and takes actions as warranted.

The Battle Creek VA Medical Center Director ensures staff awareness and access to eligibility verification procedures.

The Battle Creek VA Medical Center Director expedites the full implementation of the Transfer and Admission Coordination Office including a centralized phone number and monitors compliance with the standardized checklist.

The Battle Creek VA Medical Center Director expedites the completion and implementation of the interfacility transfers standard operating procedure and monitors compliance.

The Battle Creek VA Medical Center Director ensures the mental health residential rehabilitation treatment program standard operating procedure is aligned with Veterans Health Administration requirements regarding referral and monitors compliance.

The Veterans Integrated Service Network Director evaluates the efficacy of the Interagency Resolution Council and identification of clearly defined objectives and processes to monitor progress and address identified barriers.

The VA Houston Health Care System Director evaluates the efficiency of evidence-based psychotherapy consult management procedures; identifies barriers to timely appointment scheduling, including scheduling processes and staffing needs; and takes action as warranted.

The VA Houston Health Care System Director ensures that administrative support staff document scheduling efforts in patients’ electronic health records, as required by the Veterans Health Administration.

The VA Houston Health Care System Director ensures that staff document offering VA-issued devices for participation in virtual mental health appointments in patients’ electronic health records.

The VA Houston Health Care System Director conducts a review of providers’ lethal means safety assessment and planning with the patient, identifies barriers to effective lethal means safety discussions, and takes action as warranted.

The Under Secretary for Health clarifies the expectations and requirements for homeless program staff’s completion of suicide risk assessments and updates or reviews of safety plans for high risk for suicide patients.

The Sheridan VA Medical Center Director ensures completion of warm handoffs and Comprehensive Suicide Risk Evaluations within 24 hours for patients on the medical unit that screen positive on the Columbia-Suicide Severity Rating Scale.

The Sheridan VA Medical Center Director ensures that psychiatry or medical officer of the day staff reassess suicidal patients prior to changing a one-to-one observation status order.

The Sheridan VA Medical Center Director ensures that inpatient notes are completed and authenticated by providers as soon as possible, but always within 24 hours, in accordance with facility policy.

The Sheridan VA Medical Center Director ensures that staff follow facility policies for removing belongings and environmental risks for suicidal patients on one-to-one observation status on the medical unit.

The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System rapid response policy is in alignment with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation.

The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System policies and procedures related to responding to medical emergencies do not conflict.

The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System policy is in alignment with Veterans Health Administration Directive 1101.14, Emergency Medicine.

The Phoenix VA Health Care System Director ensures layperson cardiopulmonary resuscitation training is offered in accordance with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation.

The Phoenix VA Health Care System Director determines the need for, and implements placement of, public access automated external defibrillators in accordance with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation

The Phoenix VA Health Care System Director assesses outpatient clinic compliance with vital sign completion and documentation, identifies deficiencies, and takes action as warranted.

The Phoenix VA Health Care System Director reviews and assesses the need for non-clinical staff training on the use of the Joint Patient Safety Reporting system, and takes action as warranted.

The Phoenix VA Health Care System Director ensures complaints are reviewed and addressed in accordance with Veterans Health Administration Directive 1003.04, VHA Patient Advocacy.

The Phoenix VA Health Care System Director reviews organizational communication channels and ensures consistency with Veterans Health Administration high reliability organization principles and I CARE values

The Phoenix VA Health Care System Director makes certain that investigation and closure of events placed into the Joint Patient Safety Reporting system are completed per the Veterans Health Administration’s established time frame, and monitors compliance.

The Hampton VA Medical Center Director conducts focused clinical care reviews in accordance with Veterans Health Administration requirements, and monitors for compliance.

The Hampton VA Medical Center Director ensures that summary suspensions are conducted in accordance with Veterans Health Administration policy, and monitors for compliance.

The Hampton VA Medical Center Director confirms that proposed reduction or revocation of privileges complies with Veterans Health Administration policies and procedures, and monitors for compliance.

The Hampton VA Medical Center Director complies with Veterans Health Administration requirements when reporting licensed independent practitioners to state licensing boards.

The Hampton VA Medical Center Director completes a review of Medical Executive Committee meeting minutes and ensures recommendations made for focused professional practice evaluations for cause for licensed independent practitioners have been completed according to Veterans Health Administration requirements.

The Hampton VA Medical Center Director ensures that, when providers are transitioned from an initial focused professional practice evaluation to an ongoing professional practice evaluation, the transition is reported and documented as required by Veterans Health Administration policy, and monitors for compliance.

The Hampton VA Medical Center Director ensures that ongoing professional practice evaluations include documentation of all conclusionary outcomes required by Veterans Health Administration policy.

The Hampton VA Medical Center Director ensures surgical staff have an understanding of Veterans Health Administration Joint Patient Safety Reporting submissions and tracks submissions specific to Surgical Service, and monitors for compliance.

The Hampton VA Medical Center Director completes a comprehensive review of surgical morbidity and mortality conferences and ensures facility policy and practice is in alignment with Veterans Health Administration policy and, as necessary, consults with Veterans Health Administration’s National Surgery Office and Veterans Integrated Service Network leaders, and monitors for compliance.

The Hampton VA Medical Center Director ensures that the chief of surgery has a process to identify potential cases for peer review and communicates those cases to the appropriate program staff.

The Mid-Atlantic Veterans Integrated Service Network Director confirms the Hampton VA Medical Center Director ensures that management reviews and peer reviews, if both indicated for the same incident of care, are conducted in accordance with Veterans Health Administration policy, and are not conducted concurrently.

The Hampton VA Medical Center Director considers seeking guidance from the Office of General Counsel to determine the appropriate time frame for ensuring all required elements for previously completed institutional disclosures have been met.

Update guidance mandating use of an effective date builder for rating veterans service representatives to consider earlier effective dates when granting entitlement to individual unemployability.

Develop standardized language and prioritize incorporation into the Veterans Benefits Management System to assist rating veterans service representatives in addressing all required information/elements within an individual unemployability rating narrative.

Establish additional system controls to ensure rating veterans service representatives address competency when individual unemployability has been awarded based solely on a mental condition.

Update the Veterans Benefits Administration’s procedures manual to ensure consistency among staff and clarify the language needed to satisfy the analysis requirement when granting entitlement to individual unemployability benefits.

Develop practical learning exercises for rating veterans service representatives related to individual unemployability for Virtual and In-Person Progression training.

Require rating veterans service representatives and veterans service representatives to process and demonstrate individual unemployability claim competency on veterans’ claims.

Evaluate the workload distribution methods for individual unemployability claims to increase claims processing consistency and knowledge retention.

Implement controls to allow for the capability to identify and monitor potential scheduling delays and to ensure family preferences are being met at national cemeteries.

For future acquisitions that involve stakeholders from multiple offices, establish governance to ensure all relevant administrations and staff offices are represented in key decision roles.

For future acquisitions, establish and implement a process to promote stakeholders’ understanding of system capabilities and support buy-in.

Complete the hiring actions necessary to staff the Office of Acquisition and Logistics Project Management Office.

Resolve key Integrated Financial and Acquisition Management System challenges and ongoing concerns identified by officials from the Office of Acquisition, Logistics, and Construction and the Office of Acquisition and Logistics before further deployment of the acquisition module.

The Overton Brooks VA Medical Center Director ensures the suicide prevention team utilizes information from Medora and the required Veterans Health Administration screening and evaluation tools when assessing patients’ suicide risk in response to Veterans Crisis Line requests, and monitors for compliance.

The Overton Brooks VA Medical Center Director ensures the suicide prevention team follows national requirements for documenting each contact attempt in a patient’s electronic health record when responding to Veterans Crisis Line requests, and monitors for compliance.

The Overton Brooks VA Medical Center Director ensures the suicide prevention program manager documents clinical case reviews of suicide prevention staff members’ Veterans Crisis Line request responses and addresses identified deficiencies as required by the Veterans Health Administration.

The Overton Brooks VA Medical Center Director monitors intensive care unit one-to-one observation staff assignments for compliance with facility policy, and takes action as appropriate.

The Overton Brooks VA Medical Center Director ensures the provision of mental health appointments for patients with a high risk for suicide patient record flag as required by Veterans Health Administration policy, and monitors for compliance.

The Overton Brooks VA Medical Center Director ensures that suicide prevention staff consult with patients’ treatment teams prior to inactivation of high risk for suicide patient record flags, and monitors for compliance.

The Overton Brooks VA Medical Center Director ensures timely completion of behavioral health autopsy program chart reviews and family interview contact forms, and monitors for compliance.

The Veterans Integrated Service Network Director takes steps to ensure that suicide prevention positions are posted and continues to identify additional recruitment opportunities for suicide prevention positions, as indicated.

The Under Secretary for Health requires facilities to review designated time for Maternity Care Coordinator caseload, and assigned collateral duties, to determine if additional staffing resources are needed to support Veterans Health Administration Maternity Care Coordination, and takes action as appropriate.

The Under Secretary for Health reviews timeliness of facility community care maternity care referrals to ensure timely access for routine and expedited (high-risk and late term) referrals, and takes action as appropriate.

Ensure Veterans Benefits Administration staff use improved methodologies similar to the Office of Inspector General’s review to identify eligible veterans, readjudicate claims, and send outreach letters to potential Nehmer class members who could qualify for retroactive benefits under the National Defense Authorization Act.

Ensure claims processors at screening sites understand the need to identify any claims that may warrant readjudication by meeting the Nehmer consent decree and subsequent court orders.

Update the standard operating procedures to have staff consider whether veterans’ medical records show a diagnosis of the now-covered herbicide-related diseases at the time of any prior disability benefits claim before January 1, 2021, regardless of whether a current claim is for a disease recognized by the National Defense Authorization Act.

The Under Secretary for Health conducts a review of the Veterans Integrated Service Network leaders’ awareness and oversight of the VA Eastern Colorado Health Care System’s operations including clinical staffing, hiring and retention of qualified candidates, and leaders’ adherence to high reliability organizational principles.

The Under Secretary for Health utilizes the above review to standardize Veterans Integrated Service Network leaders’ roles and responsibilities across the system to ensure each Veterans Integrated Service Network practices structured and robust oversight activities in support of high-quality healthcare delivery at each healthcare facility.

The Veterans Integrated Service Network Director conducts a review to determine whether the actions of the Facility Director, Chief of Staff, deputy chief of staff for inpatient operations, and the associate chief of staff for education created and reinforced a culture of fear and failed to adhere to high reliability organizational principles, and takes action as needed.

The Veterans Integrated Service Network Director develops and implements an avenue for VA Eastern Colorado Health Care System’s employees to provide periodic feedback regarding the culture of safety and leaders’ practice of and adherence to high reliability principles.

The Veterans Integrated Service Network Director ensures the VA Eastern Colorado Health Care System Director evaluates clinical service leader vacancies throughout the facility and takes actions to prioritize the recruitment and hiring of qualified clinical leaders.

The Veterans Integrated Service Network Director ensures human resources officers provide separating and transferring employees access to the most current version of the VA exit and transfer surveys.

The VA Eastern Colorado Health Care System Director and leaders actively seek and utilize employee exit survey data to identify challenges with employee retention, develop and implement actions to address challenges, and evaluate the effectiveness of actions.

The Under Secretary for Health evaluates the circumstances that led to Veterans Integrated Service Network leaders’ lack of awareness of the 11-month curtailment of cardiothoracic surgeries and takes action as needed to ensure effective Veterans Integrated Service Network oversight of facility clinical operations.

The Veterans Integrated Service Network Director evaluates the circumstances that led to the failure of VA Eastern Colorado Health Care System leaders to submit a proposal request and business plan to resume cardiothoracic surgeries after an 11-month pause to the Veterans Integrated Service Network Director for review and approval and takes action as needed.

The Veterans Integrated Service Network Director ensures facility leaders implement high reliability organization principles to plan for clinical operation changes that include stakeholders, service and section leaders, and staff input.

The Veterans Integrated Service Network Director ensures that the educational needs of the facility’s residents are evaluated and maintained during service and program changes, including on-site supervision, as required by Veterans Health Administration directive.

The VA Eastern Colorado Health Care System Director reviews and finalizes Facility Draft Policy 11-55 titled Call Escalation of Communication and trains attendings, fellows, residents, and staff members on the policy.

The VA Eastern Colorado Health Care System Director reviews root cause analysis requirements for interviewing individuals relevant to root cause analyses and ensures staff are trained accordingly.

The Veterans Integrated Service Network Director, in conjunction with facility leaders and optometry service leaders, conducts a comprehensive review of the quality of care provided by the optometrist, identifies deficiencies, and takes action as indicated.

The Cheyenne VA Medical Center Director ensures compliance with Veterans Health Administration requirements for state licensing board reporting of the care provided by the optometrist and takes action, including training, as indicated.

The Cheyenne VA Medical Center Director reviews optometry service proficiency processes, identifies deficiencies, and takes action as indicated.

Ensure facility staff place all orders for eligible items through the Medical/Surgical Prime Vendor program, including those that are identified as on back order.

Implement tracking mechanisms for back orders to assist the facilities in not obtaining excess supplies.

Ensure that logistics staff receive training and use the Prime Vendor Conversion and Recommendation Tool to identify commonly purchased open market items and convert those items to Medical/Surgical Prime Vendor purchases.

Identify and implement an efficient way to transfer product list updates to the inventory ordering system.

In collaboration with the Strategic Acquisition Center, identify a VA-owned system for staff to check product information, such as availability and pricing, and ensure applicable facility staff are aware of this location.

Implement a standardized, routine review of open market purchases.

Ensure that reporting tools are effective and consistently applied, and that reported issues are resolved.

Ensure that logistics staff receive relevant Medical/Surgical Prime Vendor program guidance and training.

Ensure the product list includes items that facilities need and regularly purchase so the Veterans Health Administration can expand the savings and benefits the Medical/Surgical Prime Vendor program offers.

Establish a plan to use VA’s cost accounting system information to identify alternative ways to reduce costs, enhance efficiency, and inform business decisions as identified by VA financial policy.

Ensure healthcare system staff responsible for labor cost and workload mapping are responding in a timely manner to the results of managerial cost accounting audits and correcting all identified issues.

Consider a plan to align VA North Texas Health Care System financial management practices with federal financial accounting standard practices. This could include using cost information for performance measurement, budgeting, and cost control, and making economic choices.

Ensure that healthcare system staff are made aware of policy requirements and the responsible finance office conducts monthly reviews and reconciliations on all open obligations for financial validity and take appropriate actions as required by VA Financial Policy, vol. 2, chap. 5, “Obligations” (2020), updated May 2023.

Consult with Office of General Counsel and Office of Acquisitions, Logistics and Construction to determine if any further actions are necessary, including contract modifications, to remedy and prevent future purpose statute and bona fide needs rule violations.

Establish controls to ensure cardholders comply with record retention requirements, confirm approving officials and cardholders review purchases for VA policy compliance, and ensure contracting is used when it is in the best interest of the government.

Require cardholders to submit a request for ratification for any unauthorized commitments identified.

Develop and implement a plan to ensure data accuracy and reliability in the Generic Inventory Package in accordance with Veterans Health Administration policy.

Continue to develop and implement processes to ensure all necessary reports are monitored routinely and appropriate steps are taken to ensure all supply chain performance measures are maintained in compliance with policy.

Obtain an inventory of locally managed databases, perform configuration compliance scans, provide the facility with a copy of the scan results, and monitor the facility’s remediation efforts.

Implement a process to verify system owners review user account access to locally managed databases.

Implement effective system life-cycle processes to ensure network devices meet standards mandated by the VA Office of Information and Technology Configuration Control Board.

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 controls to ensure the accuracy of user locations supporting the Lynx Duress system.

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

Implement and monitor emergency power and uninterruptible power supplies in all communication closets.

Implement grounding equipment in all communication closets.