Recommendations
481
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-00995-211 | Mismanaged Surgical Privileging Actions and Deficient Surgical Service Quality Management Processes at the Hampton VA Medical Center in Virginia | Hotline Healthcare Inspection | ||
1 The Hampton VA Medical Center Director conducts focused clinical care reviews in accordance with Veterans Health Administration requirements, and monitors for compliance.
2 The Hampton VA Medical Center Director ensures that summary suspensions are conducted in accordance with Veterans Health Administration policy, and monitors for compliance.
3 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.
4 The Hampton VA Medical Center Director complies with Veterans Health Administration requirements when reporting licensed independent practitioners to state licensing boards.
5 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.
6 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.
7 The Hampton VA Medical Center Director ensures that ongoing professional practice evaluations include documentation of all conclusionary outcomes required by Veterans Health Administration policy.
8 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.
Closure Date:
9 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.
Closure Date:
10 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.
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11 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.
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12 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.
Closure Date:
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| 23-01772-162 | VBA Needs to Improve the Accuracy of Decisions for Total Disability Based on Individual Unemployability | Review | ||
1 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.
2 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.
3 Establish additional system controls to ensure rating veterans service representatives address competency when individual unemployability has been awarded based solely on a mental condition.
4 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.
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5 Develop practical learning exercises for rating veterans service representatives related to individual unemployability for Virtual and In-Person Progression training.
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6 Require rating veterans service representatives and veterans service representatives to process and demonstrate individual unemployability claim competency on veterans’ claims.
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7 Evaluate the workload distribution methods for individual unemployability claims to increase claims processing consistency and knowledge retention.
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| 23-01773-166 | Better Collection of Family Preference Data May Minimize Risk of Burial Scheduling Delays | Audit | ||
1 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.
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| 23-00151-117 | Lessons Learned for Improving the Integrated Financial and Acquisition Management System’s Acquisition Module Deployment | Review | ||
1 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.
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2 For future acquisitions, establish and implement a process to promote stakeholders’ understanding of system capabilities and support buy-in.
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3 Complete the hiring actions necessary to staff the Office of Acquisition and Logistics Project Management Office.
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4 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.
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| 23-02898-195 | Noncompliance with Suicide Prevention Policies at the Overton Brooks VA Medical Center in Shreveport, Louisiana | Hotline Healthcare Inspection | ||
1 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.
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2 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.
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3 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.
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4 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.
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5 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.
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6 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.
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7 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.
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8 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.
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| 22-00900-186 | Review of Perceived Barriers in Coordinating Veteran Maternity Care | National Healthcare Review | ||
1 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.
2 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.
Closure Date:
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| 23-01266-78 | VBA Did Not Identify All Vietnam Veterans Who Could Qualify for Retroactive Benefits | Review | ||
1 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.
2 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.
Closure Date:
3 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.
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| 23-02179-188 | Leaders at the VA Eastern Colorado Health Care System in Aurora Created an Environment That Undermined the Culture of Safety | Hotline Healthcare Inspection | ||
1 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.
2 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.
3 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.
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4 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.
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5 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.
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6 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.
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7 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.
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| 23-02179-189 | Extended Pause in Cardiac Surgeries and Leaders’ Inadequate Planning of Intensive Care Unit Change and Negative Impact on Resident Education at the VA Eastern Colorado Health Care System in Aurora | Hotline Healthcare Inspection | ||
1 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.
2 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.
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3 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.
4 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.
5 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.
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6 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.
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| 23-00460-185 | Deficiencies in Oversight and Leadership Response to Optometry Concerns at the Cheyenne VA Medical Center in Wyoming | Hotline Healthcare Inspection | ||
1 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.
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2 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.
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3 The Cheyenne VA Medical Center Director reviews optometry service proficiency processes, identifies deficiencies, and takes action as indicated.
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11259