OpenClosed - ImplementedClosed - Not Implemented
No. 1 to Veterans Health Administration (VHA)
The Executive Chief of Staff ensures peer reviewers identify at least one aspect of care when assigning a Level 2 or 3 to a peer review.
No. 2 to Veterans Health Administration (VHA)
The Executive Chief of Staff ensures the Peer Review Committee recommends improvement actions to reviewed providers.
No. 3 to Veterans Health Administration (VHA)
The Executive Chief of Staff ensures supervisors communicate the Peer Review Committee’s recommendations to providers and ensure they implement improvement actions for all Level 2 and 3 peer reviews.
No. 4 to Veterans Health Administration (VHA)
The Executive Chief of Staff ensures service chiefs use service-specific criteria in the professional practice evaluations of licensed independent practitioners.
No. 5 to Veterans Health Administration (VHA)
The Deputy Medical Center Director ensures the Comprehensive Environment of Care Coordinator or designee schedules and ensures staff complete and document environment of care inspections at the required frequency.
No. 6 to Veterans Health Administration (VHA)
The Deputy Medical Center Director ensures the Comprehensive Environment of Care Coordinator or designee monitors environment of care inspection deficiencies until resolution.
No. 7 to Veterans Health Administration (VHA)
The Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on inpatient mental health unit sleeping room doors.
No. 8 to Veterans Health Administration (VHA)
The Deputy Medical Center Director ensures staff post hazard warning signs in all areas where potentially infectious materials are located.
No. 9 to Veterans Health Administration (VHA)
The Deputy Medical Center Director ensures staff keep patient care areas safe and clean.
No. 10 to Veterans Health Administration (VHA)
The Executive Chief of Staff ensures suicide prevention coordinators report suicide-related events to mental health leaders and quality management staff at least monthly
No. 11 to Veterans Health Administration (VHA)
The Executive Chief of Staff ensures designated staff complete a Comprehensive Suicide Risk Evaluation on the same calendar day as a positive suicide risk screen, when logistically feasible and clinically appropriate, for all ambulatory care patients.
No. 12 to Veterans Health Administration (VHA)
The Executive Chief of Staff ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.