OpenClosed - ImplementedClosed - Not Implemented
No. 1 to Veterans Health Administration (VHA)
The Southeast Network Director facilitates a comprehensive review of Patient A’s episode of care, from the time and date of the patient’s hospitalization through the date and time of the patient’s death, to identify practitioner and process improvements that may reduce the potential for future incidents, and takes appropriate actions.
No. 2 to Veterans Health Administration (VHA)
The Columbia VA Health Care System Director ensures providers carefully consider facility resources when evaluating medically-complex patients for admission and when determining whether admitted patients’ medical complexities exceed the facility’s capabilities to meet patients’ needs.
No. 3 to Veterans Health Administration (VHA)
The Columbia VA Health Care System Director ensures that the peer review committee record the committee members formal discussions specific to the peer review in meeting minutes, and monitors ongoing compliance.
No. 4 to Veterans Health Administration (VHA)
The Columbia VA Health Care System Director evaluates quality management practices that impede the timeliness of institutional disclosures, ensures current practices are in alignment with Veterans Health Administration policy, and takes action as warranted.
No. 5 to Veterans Health Administration (VHA)
The Columbia VA Health Care System Director ensures that root cause analyses are completed within the required 45-day time frame to promptly identify and address system vulnerabilities.
No. 6 to Veterans Health Administration (VHA)
The Columbia VA Health Care System Director facilitates a comprehensive administrative review of the vascular surgeon’s disregard of surgical and invasive procedure protocols and Stop the Line principles, consults with the Office of Regional Counsel and human resource specialists, and takes administrative actions, as appropriate.
No. 7 to Veterans Health Administration (VHA)
The Columbia VA Health Care System Director evaluates facility staff’s informed consent and time-out practices, to include the review of pertinent medical images, and ensures practices are consistent with correct surgery and invasive procedure requirements, takes action as appropriate, and monitors compliance.