Open Recommendations

The VA Greater Los Angeles Healthcare System Director considers conducting peer reviews for the clinical staff involved in the patients care from day 30 through day 32, to identify opportunities to strengthen clinical practices and improve the quality of patient care.

The VA Greater Los Angeles Healthcare System Director ensures that inpatient nurses receive training on the National Early Warning Signs assessment related to the assessments administration, intervention, escalation, and documentation; establishes a process to monitor inpatient nurses adherence; and conducts audits to ensure improved and sustained compliance.

The VA Greater Los Angeles Healthcare System Director ensures nursing staff have knowledge of and timely access to the accurate names and contact numbers for patients on-call provider teams and the medical officer of the day, and addresses and closely monitors discrepancies as warranted.

The VA Greater Los Angeles Healthcare System Director reviews [Standard Operating Procedure] SOP-00-QM-100, Clinical and Administrative Escalation Process, May 28, 2025; ensures the procedure meets facility and service-line needs; and confirms information is disseminated to relevant leaders, providers, and nursing staff.

The VA Greater Los Angeles Healthcare System Director ensures nursing shift assessments electronic health record documentation is completed, timely, and at frequencies required by Veterans Health Administrations nursing policies and procedures; takes corrective action as indicated; and establishes a process to monitor for improved and sustained compliance.

The VA Greater Los Angeles Healthcare System Director evaluates the circumstances surrounding the death of the patient to ensure completion of comprehensive quality review process(es) in alignment with Veterans Health Administration standards on patient safety and high reliability that identify root causes and provide actions that enhance patient safety and mitigate similar events.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

The District Director ensures district leaders follow the Readjustment Counseling Service policy requirements to provide oversight of morbidity and mortality review panel member assignments and report completion.

The District Director identifies reasons for noncompliance with documentation requirements of high-risk client contacts and outcomes in RCSNet and the High Risk Suicide Flag SharePoint site, ensures requirements are met, and monitors compliance.

The Readjustment Counseling Service Chief Officer considers developing an additional written policy for High Risk Suicide Flag SharePoint site disposition and related RCSNet documentation.

Develop and implement a plan to fill the vacant positions needed at the Santa Clarita Processing and Distribution Center.

Develop and implement a plan to confirm mail processing and logistics employees effectively communicate, especially during peak dispatch hours, at the Santa Clarita Processing and Distribution Center.

Develop a plan to remove excess mail transport equipment from the docks and verify these are removed timely to maximize capacity at the Santa Clarita Processing and Distribution Center.

Properly reconcile the Surface Visibility scanners in Ethos and at the facility and take measurable actions to retrieve all lost scanners at the Santa Clarita Processing and Distribution Center.

Provide oversight and verify employees sign in and out Surface Visibility scanners at the Santa Clarita Processing and Distribution Center.

Secure scanners and verify only authorized employees can enter the Surface Visibility scanner room at the Santa Clarita Processing and Distribution Center.

Verify all drivers are securing trailer cargo and are using wheel chocks at the Santa Clarita Processing and Distribution Center.

Facility leaders ensure staff follow facility policies and maintain a clean environment.

Facility leaders ensure staff develop service-level workflows for the communication of urgent, noncritical test results.

Executive leaders monitor the effectiveness of the patient notification process.

The under secretary for health require the chief operating officer to direct the Veterans Integrated Service Network directors to fully integrate the core services in accordance with policy to improve operational efficiencies and access for veterans.

The under secretary for health establish a process requiring medical facility directors to coordinate with the Office of Integrated Veteran Care and the clinical contact centers before setting up or maintaining a local phone queue for services the clinical contact center provides.

The under secretary for health require the Office of Integrated Veteran Care to direct the clinical contact center leaders to determine if schedulers are arbitrarily ending calls in the telephone system to remain in after-call work status longer than needed to reduce the number of calls routed to them.

The under secretary for health direct clinical contact center leaders to routinely evaluate and, if needed, address schedulers handle time and availability time to improve performance and reduce inefficiencies.

The under secretary for health direct the Office of Integrated Veteran Care to include schedulers handle time and availability time as part of VA Health Connects annual performance plans to make sure clinical contact centers monitor and address these areas.