Open Recommendations

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff complete the Columbia-Suicide Severity Rating Scale within 24 hours before discharge and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures that staff address ways to make veterans environments safer from potentially lethal means in safety plans and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director ensures staff comply with Skills Training for Evaluation and Management of Suicide requirements and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures that the sally port inpatient unit doors are synchronized and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director establishes an interdisciplinary safety inspection team that meets VHA requirements and ensures ongoing compliance.

The VA Central Western Massachusetts Healthcare System Director uses VHA guidelines to develop facility-specific policy for the use of restraint chairs.

The VA Central Western Massachusetts Healthcare System Director ensures alignment between use of physical restraint policies and practices.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures compliance with VHA requirements for Mental Health Environment of Care Checklist training completion.

Establish a Risk Management Committee and include key personnel and stakeholders from different CFTC Divisions.

Create the Governance Charter and hold regular meetings with the Risk Management Committee.

Update and finalize an ERM roadmap from 2020 which includes estimated and actual completion dates.

Develop Annual Risk Analysis Reports and distribute to the various divisions.

Implement an Enterprise Governance, Risk and Compliance (eGRC) Tool which will help aggregate risks across the enterprise and map them to strategic objectives.

Enhance ERM communication channels and hold regular meetings between the ERM team and departments.

Increase CFTC leadership support and conduct regular briefings and workshops, and actively participate in ERM activities.

Foster a collaborative environment by appointing ERM liaisons within each division.

Conduct training sessions to educate employees about the ERM program and its benefits.

Develop a formal ERM policy that outlines the framework, objectives, and scope of the program. This policy should be approved by senior management and communicated across the organization.

Create standardized procedures to conduct ERM assessments including guidelines for risk identification, assessment, mitigation, and monitoring.

Define its ERM risk rating methodology to consistently evaluate and prioritize risks and align this methodology with the organization’s risk appetite and tolerance levels.

Maintain a centralized risk register to document all identified risks as well as the risk owners, mitigation strategies, and monitoring plans.

Establish a timeline and criteria for conducting regular risk assessments and continuously monitoring and managing risk with at least an annual risk assessment.

Regularly review and update the ERM program to incorporate best practices and lessons learned to strive for continuous improvement.

Enhance its ERM team capacity and prioritize hiring skilled ERM professionals and provide ongoing training to existing staff.

Ensure ERM considerations are integrated into the strategic planning process with active involvement from senior executives.