Open Recommendations

The Human Capital Officer should establish a formal written policy that requires managers to conduct quarterly touchpoint discussions with new employees in their first year and require that managers attend the updated training on conducting quarterly touchpoint activities.

The Human Capital Officer should work with the ITM administrator to add quarterly touchpoint activities to the manager’s ITM module as part of the new employee onboarding, send managers notifications of upcoming due dates for quarterly touchpoint activity discussions and alert managers if the discussions are past due.

The Oklahoma City VA Health Care System Director, with Pathology and Laboratory Medicine Service leaders, conducts a comprehensive review of the quality of care for the four patients identified in this report, including determinations of cytopathology processing delays and assessment of patient harm, and takes action as warranted.

The Oklahoma City VA Health Care System Director ensures that routine non-gynecological turnaround time corrective actions are documented and monitored for effectiveness, as required by the Veterans Health Administration.

The Oklahoma City VA Health Care System Director conducts a comprehensive review of the quality of care provided by the Chief of Pathology and Laboratory Medicine Service, identifies deficiencies, and takes action as warranted.

The Oklahoma City VA Health Care System Director reviews the Pathology and Laboratory Medicine Service event reporting requirements for variance events and ensures completion according to facility policy and Veterans Health Administration requirements.

The Oklahoma City VA Health Care System Director, in conjunction with the National Center for Patient Safety, evaluates patient safety event reporting processes within the Pathology and Laboratory Medicine Service, and ensures completion according to Veterans Health Administration requirements.

The Oklahoma City VA Health Care System Director, with Pathology and Laboratory Medicine Service leaders, conducts a comprehensive review of the quality of care for the four patients identified in this report, including determinations of cytopathology processing delays and assessment of patient harm, and takes action as warranted.

The Oklahoma City VA Health Care System Director ensures that routine non-gynecological turnaround time corrective actions are documented and monitored for effectiveness, as required by the Veterans Health Administration.

The Oklahoma City VA Health Care System Director conducts a comprehensive review of the quality of care provided by the Chief of Pathology and Laboratory Medicine Service, identifies deficiencies, and takes action as warranted.

The Oklahoma City VA Health Care System Director reviews the Pathology and Laboratory Medicine Service event reporting requirements for variance events and ensures completion according to facility policy and Veterans Health Administration requirements.

The Oklahoma City VA Health Care System Director, in conjunction with the National Center for Patient Safety, evaluates patient safety event reporting processes within the Pathology and Laboratory Medicine Service, and ensures completion according to Veterans Health Administration requirements.

Implement vulnerability management processes to ensure all vulnerabilities are identified and plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines.

Implement a more effective baseline configuration process to ensure network devices and databases are running authorized software that is configured to approved baselines and free of vulnerabilities.

Perform a cost-benefit analysis and implement appropriate controls within the federal Electronic Health Record to limit disclosure of veteran personally identifiable information based on job responsibility.

Segregate the duties of maintaining key stock and making keys.

Place network infrastructure equipment in a communications closet or approved enclosure to restrict access to only authorized personnel.

Complete the installation of grounding measures for all telecommunications closets to protect information technology equipment against electromagnetic pulse attack or electrostatic discharge. Ensure the work completed by contractors adheres to the requirements as defined in the work order.

Enforce the requirement for unit management to monitor fuel card purchases, including annotating all high-risk fuel transactions with an appropriate comment.

Reevaluate FAA's Business Staffing Rules so that workload, fleet count based on make/model/series, and aircraft models and series with separate maintenance review board reports are considered in the staffing algorithm for each inspector position.

Require that an independent workplace survey of the FAA United CMO be conducted to determine how inspector fleet assignments and workload distribution are impacting office culture. This should include implementing an action plan to address these needs.

Establish and implement an action plan to address FAA's documented staffing shortages and provide continuous resources to the United CMO that addresses retirement trends, average training time, and staffing turnover for a period longer than 3 years to ensure sufficient oversight.

Develop a strategic plan to provide outreach and education to the entire inspector work force on the protections of Safety Management System (SMS) data once the designation of protection is published in the Federal Registry. This should include education on inspectors' ability to request and review an air carrier's SMS data and records when conducting surveillance and addressing non-compliances.

Develop and implement a policy for FAA personnel to determine when an inspection should be postponed based on the percentage and/or type of questions that cannot be answered. This should include a management control so that FAA personnel with authority to assign inspections use "resources not available" when this threshold is met.

Provide analytical support from FAA's Safety Analysis Branch to CMOs to gather, analyze, and trend data for questions that have been answered "not observable" to support risk-based decision making.