Open Recommendations

We recommend that BCBST [redacted].

We recommend that BCBST [redacted].

We recommend that BCBST develop a process and frequency to review service accounts.

We recommend that BCBST [redacted].

We recommend that BCBST [redacted].

We recommend that BCBST review its service accounts for compliance with account management requirements. Note - this recommendation cannot be implemented until the controls from Recommendation 5 are in place.

We recommend that BCBST [redacted].

We recommend that BCBST [redacted].

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.

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.

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.

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

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.

The under secretary for health make sure the Office of Integrated Veteran Care and chief operating officer evaluate VA Health Connect staffing for scheduling and, if necessary, reallocate staff so all clinical contact centers provide core services and meet required performance standards for scheduling.

The under secretary for health direct the Office of Integrated Veteran Care to formalize and clarify internal waiver guidance and include examples of the specific evidence that would be required for a clinical contact center not to provide 24-hour services"such as exploring the use of other strategies like routing calls to another service or partnering with other centers to provide coverage.

The under secretary for health ensure the assistant under secretary for health for the Office of Integrated Veteran Care and chief operating officer periodically review the clinical contact center waiver submissions and the planned actions to comply with VA Health Connect requirements.

The under secretary for health direct the Office of Integrated Veteran Care to formalize and clarify internal waiver guidance and include examples of the specific evidence that would be required for a clinical contact center not to provide 24-hour services"such as exploring the use of other strategies like routing calls to another service or partnering with other centers to provide coverage.