Recommendations
716
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-03167-110 | Comprehensive Healthcare Inspection of the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same calendar day as a patient’s positive suicide risk screen in all ambulatory care settings.
Closure Date:
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| 23-01450-114 | Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the VA Central Ohio Healthcare System in Columbus | Hotline Healthcare Inspection | ||
1 The Deputy Secretary ensures mitigation of the high-risk pharmacy-related patient safety issues identified during the May 2021 National Center for Patient Safety visit.
2 The Under Secretary for Health evaluates whether the new electronic health record reflects accurate patient medication information per Veterans Health Administration requirements and takes action as indicated.
Closure Date:
3 The Deputy Secretary ensures the resolution of pharmacy-related usability issues identified in this report.
4 The Deputy Secretary ensures correction of inaccurate medication data transmitted to the Health Data Repository.
Closure Date:
5 The Under Secretary for Health determines the need for and implements a comprehensive strategy to review patients affected by inaccurate medication data transmitted to the Health Data Repository to evaluate whether harm occurred, the need for patients to undergo testing or treatment, and the appropriateness of institutional disclosures.
Closure Date:
6 The Under Secretary for Health ensures patients affected by inaccurate medication data transmitted to the Health Data Repository are notified of the risk of harm per Veterans Health Administration requirements.
Closure Date:
7 The Under Secretary for Health ensures legacy site providers are aware of mitigations needed for patients previously treated at a new electronic health record site and monitors compliance.
Closure Date:
8 The Under Secretary for Health ensures that pharmacist staffing levels are assessed and addressed prior to the implementation of the new electronic health record at additional VA sites
Closure Date:
9 The Under Secretary for Health evaluates the underlying technical and functional issues resulting in workarounds and educational materials needed to perform pharmacy-related operations within the new electronic health record and takes action as indicated.
Closure Date:
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| 23-00382-100 | Scheduling Error of the New Electronic Health Record and Inadequate Mental Health Care at the VA Central Ohio Healthcare System in Columbus Contributed to a Patient Death | Hotline Healthcare Inspection | ||
1 The Deputy Secretary establishes ongoing monitors to ensure that scheduling procedures in the new electronic health record are functioning in accordance with Veterans Health Administration requirements.
Closure Date:
2 The Under Secretary for Health evaluates minimum scheduling effort requirements for mental health appointments and takes action to ensure the implementation of standardized policy and procedures in the best interest of patient care.
3 The VA Central Ohio Healthcare System Medical Center Director conducts a full review of the care of the patient provided by the nurse practitioner and psychologist 1, and the supervisory psychologist’s oversight, consults with Human Resources and General Counsel Offices, and takes actions as warranted.
Closure Date:
4 The VA Central Ohio Healthcare System Medical Center Director ensures compliance with the Caring Communication Program including the initiation and cessation of caring communications as required.
Closure Date:
5 The Under Secretary for Health considers establishing written guidance related to documentation, leaders’ review, follow-up actions, and tracking of Lessons Learned in root cause analyses.
Closure Date:
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| 23-01746-112 | Inadequacies in Patient Safety Reporting Processes and Alleged Deficient Quality of Care Prior to a Patient’s Foot Amputation at the Edward Hines, Jr. VA Hospital in Hines, Illinois | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director ensures that patient advocacy staff within Veterans Integrated Service Network 12 are educated on the need to consult with patient safety staff when complaints involve patient safety concerns.
Closure Date:
2 The Edward Hines, Jr. VA Hospital Director ensures a review is completed of the missed opportunities referenced in this report related to refitting and reeducating patients on VA-issued shoes, determines the need to create a related standard operating procedure or facility policy, and takes action as necessary.
Closure Date:
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| 23-06147-111 | Logistics Managers Improperly Allowed Employees to Auction Off Government Property | Administrative Investigation | ||
1 Ensure the DALC Recreation Group’s operations fully comply with VA Handbook 5025, Part VIII, or dissolve the group if there is insufficient employee interest in its continuation.
Closure Date:
2 Update VA Handbook 7002, Logistics Management Procedures Part 3, section 7, to clarify under which circumstances, if any, VA employees are permitted to request, accept, and record any incentive items provided by vendors in connection with government purchases.
Closure Date:
3 Reinforce ethics and policy requirements on the acceptance and disposition of free or donated property with all Denver Logistics Center managers and staff, including distributing to staff the Office of General Counsel’s guidance dated June 30, 2023.
Closure Date:
4 Reeducate DLC managers, approving officials, and purchasing agents about VA government purchase card policy requirements that government contracted sources be fully considered and given priority when making purchases.
Closure Date:
5 In consultation with the Office of General Counsel, as authorized by 31 U.S.C. § 3711, determine the full magnitude of the loss from the DALC Recreation Group’s improper sale of VA property and take appropriate action to recover the losses, including any proceeds of the auctions currently within the custody or control of the DALC Recreation Group.
Closure Date:
6 Consider whether any administrative action should be taken with respect to the conduct or performance of the director of the Denver Logistics Center or any other individual involved in the improper acquisition and disposition of the incentive items, and report to the OIG any actions taken involving these individuals.
Closure Date:
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| 23-00117-108 | Comprehensive Healthcare Inspection of the Beckley VA Medical Center in West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs incorporate service-specific criteria in licensed independent practitioners’ Ongoing Professional Practice Evaluations.
Closure Date:
2 The Chief of Staff ensures service chiefs regularly monitor licensed independent practitioners’ performance through Ongoing Professional Practice Evaluations.
Closure Date:
3 The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.
Closure Date:
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| 22-01275-99 | Transition to VA Health Care and Utilization of Benefits for Veterans Who Reported Sexual Assault During Military Service | National Healthcare Review | ||
1 The Under Secretary for Health examines potential differences between the veterans who reported to Sexual Assault Prevention and Response Office and used VA health care and those who did not in order to improve outreach efforts to the nearly half who did not engage with VA health care.
Closure Date:
2 The Under Secretary for Benefits evaluates the service-connected disability application and claims process for veterans who reported sexual assault that occurred during military service to identify and mitigate potential barriers.
Closure Date:
3 The Under Secretary for Benefits examines potential differences between the veterans who reported to Sexual Assault Prevention and Response Office and used VA benefits and those who did not in order to improve outreach efforts.
Closure Date:
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| 23-00528-92 | Deficiencies in Quality of Care at VA Maine Healthcare System in Augusta | Hotline Healthcare Inspection | ||
1 The VA Maine Healthcare System Director confirms that staff complete the Columbia-Suicide Severity Rating Scale and document on the Veterans Health Administration template when patients are unwilling to participate in completion of the screening.
Closure Date:
2 The VA Maine Healthcare System Director oversees a review to determine whether a VA Maine Healthcare System policy in which clinical staff will be expected to develop safety plans with patients is needed; and if so, ensures one is created.
Closure Date:
3 The VA Maine Healthcare System Director verifies that patients identified as having suicidal ideations or behaviors have personalized safety plans documented in the electronic health record, and monitors compliance.
4 The VA Maine Healthcare System Director assesses staff knowledge of when to notify the VA Maine Healthcare System suicide prevention staff about a patient who has made a threat of self-directed violence during a phone call with VA staff, and takes action as warranted.
Closure Date:
5 The VA Maine Healthcare System Director ensures that VA Maine Healthcare System leaders and root cause analysis teams are trained in the process for responding to concerns with root cause analysis team findings according to VA National Center for Patient Safety guidance, and monitors adherence.
Closure Date:
6 The VA Maine Healthcare System Director ensures that a review of the episode of care prior to the patient’s death is completed to determine whether peer reviews are warranted, and takes action accordingly.
Closure Date:
7 The VA Maine Healthcare System Director confirms that VA Maine Healthcare System leaders, risk managers, and patient safety staff have knowledge of the types of quality management reviews that can and cannot be done concurrently.
Closure Date:
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| 23-00106-94 | Comprehensive Healthcare Inspection of the Central Alabama Veterans Health Care System in Montgomery | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.
2 The Chief of Staff ensures the Suicide Prevention Coordinator reports suicide-related events monthly to mental health leaders and quality management staff.
Closure Date:
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| 23-00023-96 | Comprehensive Healthcare Inspection of the Charles George VA Medical Center in Asheville, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures the Patient Safety Manager documents start dates for sentinel event investigations in the Joint Patient Safety Reporting system.
Closure Date:
2 The Director ensures the Patient Safety Manager initiates a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
Closure Date:
3 The Director ensures executive leaders consolidate all credentialing and privileging activities into one credentialing and privileging office under the Chief of Staff.
Closure Date:
4 The Director ensures the Credentialing and Privileging Manager reports directly to the Chief of Staff.
Closure Date:
5 The Director ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.
Closure Date:
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11259