Open Closed - Implemented Closed - Not Implemented

No. 1 to Veterans Health Administration (VHA) The Robert J. Dole VA Medical Center Director ensures that Emergency Department physicians receive training on the facility’s acute coronary syndrome protocol and verifies that ST-elevation myocardial infarction time goals are monitored, and improvements implemented as needed.

No. 2 to Veterans Health Administration (VHA) The Robert J. Dole VA Medical Center Director makes certain a facility policy that is applicable to all patient care areas outlines standardized processes for safe and timely interfacility transfers, including communication of appropriate transport services needed.

No. 3 to Veterans Health Administration (VHA) The Robert J. Dole VA Medical Center Director conducts an analysis of the contributing factors that led to the delay in the patient’s interfacility transfer and takes action as necessary to improve identified deficiencies.

No. 4 to Veterans Health Administration (VHA) The Robert J. Dole VA Medical Center Director ensures the newly implemented Emergency Department Interfacility Transfers policy is reviewed and updated to include improvements as data are obtained from the interfacility transfer analysis.

No. 5 to Veterans Health Administration (VHA) The Robert J. Dole VA Medical Center Director makes certain that Emergency Department and Health Administrative Service staff are trained on the Emergency Department Interfacility Transfers policy, the updated service agreement between Cardiology and Emergency Departments, and interfacility transfer process and monitors the transfer process, including timeliness of transfers.

No. 6 to Veterans Health Administration (VHA) The Robert J. Dole VA Medical Center Director ensures the Critical Care Committee evaluates all concerns identified during code events, makes recommendations for improvement, confirms actions are implemented, and assesses effectiveness of actions.

No. 7 to Veterans Health Administration (VHA) The Robert J. Dole VA Medical Center Director ensures the Chief, Quality Management is a member of the Critical Care Committee, develops a process to address problems in obtaining the assistance of Emergency Medical Services or use of the 911 call system, and assesses the effectiveness of the process.

No. 8 to Veterans Health Administration (VHA) The VA Heartland Network Director reviews the peer reviews of physicians who provided care to the patient to determine if a focused clinical review by an independent reviewer is warranted and takes actions as necessary.

No. 9 to Veterans Health Administration (VHA) The Robert J. Dole VA Medical Center Director reviews the patient’s care provided in the Emergency Department and the circumstances of the interfacility transfer to determine if an institutional disclosure is warranted.