Dental VA Recovery Plan Template

Use this template for performance problems. Follow the appropriate formal process for suspected misconduct, privacy incidents, security events, or legal matters.

Problem and evidence

Affected workflow: ______

Observed result: ______

Examples, dates, and measures: ______

Expected standard: ______

Working cause

Expectation / process / provider / skill / judgment / reliability / role fit

Why this is the likely cause: ______

Actions

Practice will: ______

VA will: ______

Provider will, if applicable: ______

Procedure, training, access, or scope changes: ______

Review plan

Temporary review rate: ______

Success measure and threshold: ______

Sample size or evidence period: ______

Checkpoint date: ______

Decision at checkpoint

Continue and restore prior autonomy / extend the plan / re-scope / replace / switch provider / end engagement

Reason and evidence: ______

What changes before any new person begins: ______