OpenClosed - ImplementedClosed - Not Implemented
No. 1 to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
No. 2 to Veterans Health Administration (VHA)
The Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
No. 3 to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines reasons for noncompliance and ensures section or service chiefs define time frames for Focused Professional Practice Evaluations.
No. 4 to Veterans Health Administration (VHA)
The Chief of Staff determines the reasons for noncompliance and ensures service chiefs include service-specific criteria in Ongoing Professional Practice Evaluations.
No. 5 to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures Medical Executive Council meeting minutes consistently contain its recommendations for privileging requests
No. 6 to Veterans Health Administration (VHA)
The Associate Director, Operations evaluates and determines any additional reasons for noncompliance and ensures staff inspect, test, and maintain all medical equipment.
No. 7 to Veterans Health Administration (VHA)
The Director evaluates and determines any additional reasons for noncompliance and ensures staff maintain equipment and furnishings in good working order and keep areas used by patients clean, safe, and suitable for care.
No. 8 to Veterans Health Administration (VHA)
The Director evaluates and determines reasons for noncompliance and ensures that only breathable shower curtains are present in mental health inpatient unit bathrooms.
No. 9 to Veterans Health Administration (VHA)
The Chief of Staff or Associate Director, Patient Care Service/Nurse Executive determines the reasons for noncompliance and ensures video or audio monitoring equipment installed for patient safety purposes does not record and is only accessed and viewed by Veterans Affairs healthcare providers.