Open Recommendations

The Associate Director for Operations ensures staff keep patient care areas clean and clean storage areas free of dirty items and equipment.

The Chief of Staff ensures the facility has workflows for all services to identify team members’ roles in the test result communication process.

Facility leaders assess how staff monitor video laryngoscope supplies to ensure they are readily available, and staff remove supplies when they expire.

Facility leaders ensure staff develop service-level workflows for the communication of test results per the VHA directive.

Ensure medical facilities establish and implement clear written Homeless Screening Clinical Reminder policies that define the roles and responsibilities of staff involved in the referral, follow-up, and monitoring processes.

Ensure medical facility staff involved in the Homeless Screening Clinical Reminder process are aware of and trained on written local policies and procedures for making referrals, conducting follow-up, and monitoring.

Develop and implement a review process to determine whether medical facility staff followed local Homeless Screening Clinical Reminder policies whenever a veteran does not receive a follow-up encounter within 30 days of a positive screening and correct any identified deficiencies.

Ensure all medical facilities have a reliable report that accurately lists veterans who screened positive and accepted referrals as well as the status of follow-up actions.

We recommend that the Commissioner of the Public Buildings Service coordinate with the tenant agency at the Oroville LPOE range to assess the target retrieval system operation and determine a corrective action plan to address any issues identified.

We recommend that the Commissioner of the Public Buildings Service develop and issue a comprehensive policy that, at a minimum, establishes roles and responsibilities for the operation and maintenance of the indoor firing ranges; document retention requirements; and comprehensive inspection and cleaning procedures.

The VA Detroit Healthcare System Director ensures pathology and laboratory medicine service leaders communicate feedback regarding staff-specific errors to facilitate staff learning and according to Veterans Health Administration high reliability organization guidance.

The VA Detroit Healthcare System Director evaluates the quality and patient safety service response to patient safety events, including tracking and monitoring of service level corrective action plans to ensure timely resolution of patient safety events, and takes action as necessary.

The VA Detroit Healthcare System Director verifies pathology and laboratory medicine service leaders demonstrate clear communication of the laboratory quality management technologist roles and responsibilities in accordance with Veterans Health Administration requirements.

The VA Detroit Healthcare System Director ensures the pathology and laboratory medicine service will sustain oversight of manual complete blood count with differential reads for accuracy via retrospective pathologist secondary reviews.

The VA Detroit Healthcare System Director makes certain that pathology and laboratory medicine service leaders track variance reporting and ensure completion of applicable corrective action in accordance with facility policy and Veterans Health Administration requirements.

Rec. 1.a: The DoD recommended that the Defense Health Agency Director finalize and implement guidance that establishes the Defense Health Agencys expectations and roles and responsibilities for access to care, incorporating the Defense Health Agencys new structure and positions and updated practices. If the Defense Health Agency cannot finalize and implement guidance within 90 days of the final report, then it should issue formal interim guidance to the military medical treatment facilities to establish access to care requirements until the Defense Health Agency implements the finalized guidance.

Rec. 1.b: The DoD recommended that the Defense Health Agency Director perform a comprehensive analysis to determine consistent themes across military medical treatment facilities concerns with the reliability, accuracy, and completeness of data used to monitor and remediate issues with the access to care metrics.

Rec. 1.c: The DoD recommended that the Defense Health Agency Director designate a centralized location accessible to the defense health networks and military medical treatment facilities personnel that communicate whether data issues are widespread or localized, and the status of resolution.

Rec. 1.d: The DoD recommended that the Defense Health Agency Director develop and implement a remediation plan to prioritize and fix data issues with the Defense Health Agency Near Real Time dashboard data on access to care.

Rec. 1.e: The DoD recommended that the Defense Health Agency Director develop and implement a standardized process that collects data identifying why military medical treatment facility personnel left their position.

Rec. 1.f: The DoD recommended that the Defense Health Agency Director develop and implement a process to analyze and track trends to ensure that the Defense Health Agency has mitigation strategies for common reasons that personnel leave the military medical treatment facilities.

Rec. 1.g: The DoD recommended that the Defense Health Agency Director perform a comprehensive review of the staffing at military medical treatment facilities outside the continental United States to ensure military medical treatment facilities are authorized the staffing necessary to support the primary care staffing models.

Rec. 1.h: The DoD recommended that the Defense Health Agency Director expand the provider deduction tool to include tracking of support staff availability to ensure a comprehensive picture of overall clinic availability in meeting access to care standards.

Rec. 2.a: The DoD recommended that the Defense Health Agency Director in coordination with the Military Departments conduct a workload analysis study in primary care to observe and measure the time that primary care providers spend on supporting the DHA health care and DoD readiness missions.

Rec. 2.b: The DoD recommended that the Defense Health Agency Director, in coordination with the Military Departments, implement guidance to provide appropriate FTE deductions for collateral duties such as supporting the Exceptional Family Member Program.