All Reports

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.

The Director takes appropriate actions so fire doors close completely and latch, as required by National Fire Protection Association 80 Standard for Fire Doors and Other Opening Protectives.

The Director takes appropriate actions so staff update the facility policy on test result communications to meet the requirements of Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services/Nurse Executive take appropriate actions so staff develop, for each service, written workflows consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions for the Chief of Staff to review Patient Centered Management Module data and address efficiency, capacity, and staffing needs, in accordance with Veterans Health Administration Directive 1406(3), Patient Centered Management Module (PCMM) for Primary Care.

The Director develops workflows for all services that communicate test results to patients and includes the process for assigning designees (surrogates) for providers who order tests in the facility’s policy, 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 for communicating test results.

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.

Facility leaders implement measures to keep all eyewash stations clean and safe for emergency use.

Facility leaders implement measures to keep walkways free of obstructions to maintain clear exit routes.

The Director updates the facility’s written policy for test result communications to comply with requirements in Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director of Patient Care Services/Nurse Executive develop and implement written workflows for each service that comply with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

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.

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.

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.