Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. --

Combined Assessment Program 

Review of the 

Battle Creek VA Medical Center

Battle Creek, Michigan

$XJXVW

Washington, DC 20420
Why We Did This Review

Combined Assessment Program (CAP) reviews are part of the Office of Inspector 

General's (OIG's) efforts to ensure that high quality health care is provided to our 

Nation's veterans. CAP reviews combine the knowledge and skills of the OIG's Offices 

of Healthcare Inspections and Investigations to provide collaborative assessments of 

VA medical facilities on a cyclical basis. The purposes of CAP reviews are to:

• Evaluate how well VA facilities are accomplishing their missions of providing veterans 

convenient access to high quality medical services.

• Provide crime awareness briefings to increase employee understanding of the 

potential for program fraud and the requirement to refer suspected criminal activity to 

the OIG.

In addition to this typical coverage, CAP reviews may examine issues or allegations 

referred by VA employees, patients, Members of Congress, or others.

To Report Suspected Wrongdoing in VA Programs and Operations

Telephone: 1-800-488-8244

E-Mail: vaoighotline@va.gov

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 

Glossary

C&P credentialing and privileging

CAP Combined Assessment Program

CLC community living center

COC coordination of care

CPRS Computerized Patient Record System

CWAD Crises, Warnings, Allergies and/or Adverse 

Reactions, and Directives

ECMS Executive Committee of the Medical Staff

EOC environment of care

facility Battle Creek VA Medical Center

FY fiscal year

JC Joint Commission

MDRO multidrug-resistant organisms

MEC Medical Executive Committee

MRC Medical Records Committee

OIG Office of Inspector General

OPPE Ongoing Professional Practice Evaluation

PR peer review

QB Quality Board

QM quality management

SHEP Survey of Healthcare Experiences of Patients

UM utilization management 

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

VSB Veterans Satisfaction Board
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 

Table of Contents

Page

Executive Summary ................................................................................................... i

Objectives and Scope................................................................................................ 1

Objectives ............................................................................................................... 1

Scope...................................................................................................................... 1

Reported Accomplishment........................................................................................ 2

Results ........................................................................................................................ 2

Review Activities With Recommendations .............................................................. 2

Physician C&P................................................................................................... 2

Management of Test Results............................................................................. 3

QM..................................................................................................................... 4

Management of MDRO...................................................................................... 5

COC .................................................................................................................. 6

EOC................................................................................................................... 7

Comments................................................................................................................... 8

Appendixes

A. Facility Profile .................................................................................................... 9

B. Follow-Up on Previous Recommendations........................................................ 10

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 13

D. VISN Director Comments .................................................................................. 15

E. Facility Director Comments ............................................................................... 16

F. OIG Contact and Staff Acknowledgments ......................................................... 22

G. Report Distribution ............................................................................................ 23
VA OIG Office of Healthcare Inspections i

Executive Summary: Combined Assessment Program

Review of the Battle Creek VA Medical Center, 

Battle Creek, MI

Review Purpose: The purpose was 

to evaluate selected activities, focusing 

on patient care administration and 

quality management, and to provide 

crime awareness training. We 

conducted the review the week of 

March 28, 2011. 

Review Results: The review covered 

six activities. The facility’s reported 

accomplishment was the receipt of the 

2010 Award for Innovation in VA 

Community Living Centers. 

Recommendations: We made 

recommendations in the following six 

activities:

Physician Credentialing and Privileging:

Review Ongoing Professional Practice 

Evaluation data on an ongoing basis, 

and ensure service-specific competency 

criteria is approved by the Medical 

Executive Committee. Review 

privileges to determine whether those

granted are consistent with the facility’s 

clinical practices. 

Management of Test Results:

Consistently document the time critical 

results were communicated to ordering 

providers and patient notification and 

treatment actions in response to critical 

results. Communicate normal test 

results to patients within the specified 

timeframe. Monitor the process of 

communicating test results. 

Quality Management: Discuss peer 

review findings at the Medical Executive 

Committee quarterly. Discuss Utilization 

Management Committee reports at the 

Quality Board quarterly. Monitor 

unauthenticated documentation, and 

address identified medical record review 

problems. 

Management of Multidrug-Resistant 

Organisms: Provide infection prevention 

strategies education to patients and 

their families, and document it. Conduct 

and document required risk 

assessments. Ensure employees 

receive initial and annual education, and 

document it. 

Coordination of Care: Document patient 

advance care planning using approved 

progress note titles. Ensure discharge 

instructions are consistent with current 

orders and include all required

elements.

Environment of Care: Complete a risk 

assessment, and ensure all fire 

extinguishers are clearly marked, readily 

accessible, and immediately available. 

Ensure radiology department staff 

complete annual safety training, and 

document it. Place inspection dates on 

all lead shieds and aprons.

Comments 

The Veterans Integrated Service 

Network and Facility Directors agreed 

with the Combined Assessment 

Program review findings and 

recommendations and provided 

acceptable improvement plans. We will 

follow up on the planned actions until 

they are completed. 

JOHN D. DAIGH, JR., M.D.

Assistant Inspector General for

Healthcare Inspections
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 1 

Objectives and Scope

Objectives CAP reviews are one element of the OIG’s efforts to ensure 

that our Nation’s veterans receive high quality VA health care 

services. The objectives of the CAP review are to:

• Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care administration 

and QM.

• Provide crime awareness briefings to increase employee 

understanding of the potential for program fraud and the 

requirement to refer suspected criminal activity to the 

OIG.

Scope We reviewed selected clinical and administrative activities to 

evaluate the effectiveness of patient care administration and 

QM. Patient care administration is the process of planning 

and delivering patient care. QM is the process of monitoring 

the quality of care to identify and correct harmful and 

potentially harmful practices and conditions.

In performing the review, we inspected selected areas, 

interviewed managers and employees, and reviewed clinical 

and administrative records. The review covered the 

following six activities: 

• COC

• EOC

• Management of MDRO

• Management of Test Results

• Physician C&P

• QM

The review covered facility operations for FY 2010 and 

FY 2011 through March 28, 2011, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. We also followed up on selected recommendations 

from our prior CAP review of the facility (Combined 

Assessment Program Review of the Battle Creek VA Medical 

Center, Battle Creek, Michigan, Report No. 08-00399-131, 
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 2 

May 29, 2008). The facility had corrected all findings. (See 

Appendix B for further details.)

During this review, we also presented crime awareness 

briefings for 68 employees. These briefings covered 

procedures for reporting suspected criminal activity to the 

OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery.

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. 

Reported Accomplishment

2010 VA Innovation 

Award

In 2010, the facility received the Award for Innovation in VA

Community Living Centers. This award recognized Battle 

Creek’s accomplishment in transforming the CLC culture. 

Results

Review Activities With Recommendations

Physician C&P The purpose of this review was to determine whether the

facility had consistent processes for physician C&P that 

complied with applicable requirements. 

We reviewed 13 physicians’ C&P files and profiles and found 

that licenses were current and that primary source 

verification had been obtained. However, we identified the 

following areas that needed improvement.

OPPE. VHA requires that data consistent with 

service-specific competency criteria be collected, maintained 

in each physician’s profile, and reviewed on an ongoing 

basis.1

Facility-Specific Privileges. VHA requires that privileges be 

facility specific. Only privileges for procedures actually 

provided by the facility may be granted to a practitioner.

 VHA also requires the criteria to be approved by the 

MEC. For the 10 reprivileged physicians whose profiles we 

reviewed, OPPE data were not reviewed on an ongoing 

basis and did not include service-specific competency criteria

approved by the MEC. 

2

 

1 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008.

Endotracheal intubation is a procedure that is beyond the 

2 VHA Handbook 1100.19.
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 3 

scope of service designated for this facility. However, we 

found that 17 (30 percent) of the 56 providers at the facility 

were privileged to perform this procedure.

Recommendations 1. We recommended that OPPE data be reviewed on an 

ongoing basis and that service-specific competency criteria 

be approved by the MEC. 

2. We recommended that all privileges be reviewed to 

determine whether the privileges granted are consistent with 

the clinical practices of the facility. 

Management of 

Test Results

The purpose of this review was to follow up on a previous 

review that identified improvement opportunities related to 

documentation of notification of abnormal test results and 

follow-up actions taken.3

We reviewed the facility’s policies and procedures, and we 

reviewed medical records. We identified the following areas

that needed improvement.

 

Documentation of Ordering Provider Notification. VHA 

requires that diagnostic laboratory and radiology clinicians 

document in the medical record the time and means of 

critical test result communication and the name of the 

ordering provider contacted.

4

Documentation of Patient Notification and Treatment Actions. 

VHA requires ordering providers to document in the medical 

record patient notification and treatment actions in response 

to critical test results.

 We reviewed the medical 

records of 20 patients who had critical results and found that 

diagnostic clinicians did not document the time the ordering 

provider was notified in 9 of the 20 records.

5

Communication of Normal Results. VHA requires facilities to 

communicate normal results to patients no later than 

14 calendar days from the date that the results were 

available to the ordering provider.

 We reviewed the medical records of 

20 patients who had critical results and did not find 

documented evidence of patient notification and follow-up 

actions in 3 of the 20 records.

6

 

3 Healthcare Inspection Summary Review – Evaluation of Veterans Health Administration Procedures for 

Communicating Abnormal Test Results, Report No. 01-01965-24, November 25, 2002.

 We reviewed the medical 

4

VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009. 5 VHA Directive 2009-019. 6 VHA Directive 2009-019. 
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 4 

records of 20 patients who had normal results and found that 

9 of 20 records did not contain documented evidence that 

the facility had communicated the results to the patients. 

Monitoring Results Communication. VHA requires facilities 

to monitor the effectiveness of communication of results to 

providers and patients.7

Recommendations

 We determined that the facility had 

an established process for monitoring communication of 

laboratory and radiology results to ordering providers. 

However, the monitoring was based on a 60-minute 

timeframe when the time required by local policy is 

30 minutes. In addition, we did not find evidence that 

communication of test results to patients was periodically 

monitored. 

3. We recommended that diagnostic clinicians consistently 

document the time critical results were communicated to 

ordering providers and that ordering providers consistently 

document patient notification and treatment actions in 

response to critical results. 

4. We recommended that normal test results be

consistently communicated to patients within the specified 

timeframe. 

5. We recommended that the process of communicating 

test results to providers and patients be periodically 

monitored for effectiveness to ensure compliance with VHA 

and local policies. 

QM The purpose of this review was to evaluate whether the 

facility had a comprehensive QM program in accordance with 

applicable requirements and whether senior managers 

actively supported the program’s activities. 

We interviewed senior managers and QM personnel, and we 

evaluated policies, meeting minutes, and other relevant 

documents. We identified the following areas that needed 

improvement.

PR. VHA requires the MEC, or its equivalent, to review PR 

results on a quarterly basis.8 We found that the MEC

discussed PR findings in only 2 of the past 4 quarters.

 

7 VHA Directive 2009-019. 8 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010. 
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 5 

UM. Local policy requires the QB to review UM Committee 

reports quarterly. We found that the QB reviewed reports in 

only 2 of the past 4 quarters. 

Medical Records Quality Review. VHA requires the MRC to

provide oversight and coordination of medical record quality 

review activities.9

Recommendations

The MRC did not monitor unauthenticated 

documentation or ensure that action plans resulted in 

remediation of identified deficiencies.

6. We recommended that PR findings be discussed at the 

MEC quarterly.

7. We recommended that UM Committee reports be 

discussed at the QB quarterly. 

8. We recommended that unauthenticated documentation 

be monitored and that processes for addressing identified 

medical record review problems be strengthened. 

Management of 

MDRO

The purpose of this review was to evaluate whether the 

facility had developed a safe and effective program to reduce 

the incidence of MDRO in its patient population in 

accordance with applicable requirements. 

We inspected a medical unit and the CLC, and we 

interviewed four employees. We did not identify deficits in 

either the inspections or staff interviews. However, we 

identified the following areas that needed improvement.

Patient/Family Education. The JC requires that patients 

infected or colonized10

MDRO Risk Assessment. The JC requires that facilities 

conduct a risk assessment to determine the need for staff 

education. There was no evidence that the facility had 

conducted an MDRO risk assessment. 

with MDRO and their families receive 

education on infection prevention strategies, such as hand 

washing and the proper use of personal protective 

equipment. We reviewed 12 medical records and found no 

documented evidence of MDRO education.

Employee Training. Facility policy requires staff to have 

MDRO training during orientation and annually thereafter.

We reviewed 20 employee training records and found that 

 

9 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 10 Colonization is the presence of bacteria in the body without causing clinical infection.
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 6 

3 records had no documentation of initial or annual MDRO 

education.

Recommendations 9. We recommended that infection prevention strategies 

education be provided to patients infected or colonized with 

MDRO and their families and be documented.

10. We recommended that the required MDRO risk 

assessments be conducted and documented.

11. We recommended that employees receive initial and 

annual MDRO education and that the training be consistently 

documented.

COC The purpose of this review was to evaluate whether the 

facility managed advance care planning, advance directives, 

and discharges in accordance with applicable requirements.

We reviewed patients’ medical records for evidence of 

advance care planning, advance directives, and discharge 

instructions. We identified the following areas that needed 

improvement.

Advance Care Planning Progress Note Titles. VHA requires 

that staff use specific progress note titles when documenting 

advance care planning discussions with patients and link 

these notes to the CWAD posting in the electronic medical 

record.11

Discharge Instructions. VHA requires that upon discharge 

from the facility, providers include information regarding 

medications, diet, activity level, and follow-up appointments 

in instructions to patients.

 We reviewed 10 patient medical records and

determined that in two of the records, the facility did not use 

the required progress note titles. In addition, two advance 

care planning documentation notes were not linked to the 

CWAD posting.

12

We reviewed the medical records of 10 discharged patients 

and found that two records did not address all required 

elements. Additionally, we identified three patients whose 

diet orders were not consistent with their dietary discharge 

instructions.

 In addition, the JC requires that 

clinicians provide patients with written discharge instructions. 

 

11 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009. 12 VHA Handbook 1907.01.
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 7 

Recommendations 12. We recommended that staff document patient advance 

care planning using approved progress note titles and link 

the notes to the CWAD posting.

13. We recommended that processes be strengthened to 

ensure that discharge instructions are consistent with current 

orders and include all required elements.

EOC The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

We inspected the CLC, a medical unit, the urgent care area, 

a behavioral health unit, outpatient clinical areas, and 

radiology. The facility maintained a generally clean and safe 

environment. However, we identified the following areas that 

needed improvement.

Fire and Life Safety. The National Fire Protection 

Association requires portable fire extinguishers to be 

conspicuously marked, readily accessible, and immediately 

available. In all areas inspected, we found fire extinguishers 

stored in locked cabinets without conspicuous markings and 

with no means of emergency access.

Radiation Safety. Local policy requires annual radiation 

safety training for radiology department employees. We 

reviewed training records for five radiology technologists; 

none of the records had documentation of radiation safety 

training.

The Occupational Safety and Health Administration requires 

that lead shields and aprons be periodically inspected and 

that the inspection date be placed on those items. While the 

facility is conducting periodic inspections, they do not place 

the inspection dates on the shields and aprons. 

Recommendations 14. We recommended that a risk assessment be completed

and that all fire extinguishers be conspicuously marked, 

readily accessible, and immediately available.

15. We recommended that radiology department staff 

complete annual radiation safety training and that the training 

be documented.

16. We recommended that inspection dates be placed on all 

lead shields and aprons.
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 8 

Comments

The VISN and Facility Directors agreed with the CAP review findings and 

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 15–21, for the full text of the Directors’ comments.) We will follow up on 

the planned actions until they are completed. 
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

Appendix A

VA OIG Office of Healthcare Inspections 9 

Facility Profile13

Type of Organization Mental health, primary care, physical 

medicine and rehabilitation, extended care, 

and long-term care

Complexity Level 3

VISN 11

Community Based Outpatient Clinics Grand Rapids, MI

Muskegon, MI

Benton Harbor, MI

Lansing, MI

Veteran Population in Catchment Area 187,431

Type and Number of Total Operating Beds:

• Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program

239

• CLC/Nursing Home Care Unit 109

• Other N/A

Medical School Affiliation(s) Michigan State University

• Number of Residents 8

Current FY (through

March 2011) 

Prior FY (2010)

Resources (in millions): 

• Total Medical Care Budget $233.7 $221.6

• Medical Care Expenditures $116.1 $218.8

Total Medical Care Full-Time Employee 

Equivalents

1,267.3 1,268.4

Workload: 

• Number of Station Level Unique 

Patients

20,693 20,425

• Inpatient Days of Care:

o Acute Care 2,310 4,840

o CLC/Nursing Home Care Unit 15,393 31,489

Hospital Discharges 500 3,088

Total Average Daily Census (including all bed 

types)

226.3 233

Cumulative Occupancy Rate (in percent) 70.5 68

Outpatient Visits 63,457 (through 

January 2011)

374,438

 

13 All data provided by facility management.
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

Appendix B

VA OIG Office of Healthcare Inspections 10

Follow-Up on Previous Recommendations

Recommendations Current Status of Corrective Actions 

Taken

In Compliance 

Y/N

Repeat 

Recommendation? 

Y/N

QM

1. Ensure VHA requirements for PRs are 

met.

PRs are being completed within the 

required timeframe. PR minutes are 

being reported to the QB for oversight, 

and the QB is reviewing trends in 

changes from one rating level to 

another.

Y N

2. Require that patient complaint data be

compared to SHEP results and that 

corrective action be initiated and monitored. 

Patient complaint data is tracked, 

aggregated, and compared to SHEP 

survey results. The VSB discusses the 

data, the recently hired Planetree 

coordinator takes action on the 

identified opportunities, and the 

activities are reported to the ECMS. 

Y N

3. Ensure importing and copying of text in 

the electronic medical records is monitored. 

The concerns regarding importing and 

copying of text in the electronic medical 

record has been addressed. In 2008, a 

specific monitor for the “copy and 

paste” functionality was included as 

part of ongoing point of care medical 

record reviews. Additionally, 

inappropriate use of copy and paste is 

monitored on physician OPPEs.

Y N
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 11

Recommendations Current Status of Corrective Actions 

Taken

In Compliance 

Y/N

Repeat 

Recommendation? 

Y/N

4. Ensure adverse event disclosures are 

monitored in accordance with VHA policy.

Local policy, which is consistent with 

VHA policy, outlines the requirements 

for disclosure and documentation 

related to adverse events. There has 

not been an institutional adverse event 

since 2008, but all adverse events are 

tracked. 

Y N

5. Ensure the Chief of Staff conducts an 

independent review of two patients identified 

as having experienced adverse events to 

ensure that VHA policy is followed.

The Chief of Staff independently 

reviewed the two patients identified, 

and disclosures were completed 

May 30, 2008.

Y N

6. Require the facility to strengthen 

communication and collaboration among 

UM, medical care cost recovery, and fee 

basis staff.

As evidenced by local policy and the 

minutes of the UM Committee, 

communication and collaboration 

among UM, medical care cost 

recovery, and fee basis staff have 

improved.

Y N

EOC

7. Ensure infection control vulnerabilities 

are corrected.

Emergency call system cords are

properly placed and clean; medication 

refrigerators have central temperature 

control, and no damaged or dirty seals 

are evident; patient care equipment 

with compromised surfaces has been 

removed, and the remaining equipment 

is clean; and the damaged ceiling tiles 

have been replaced and are 

maintained. 

Y N
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 12

Recommendations Current Status of Corrective Actions 

Taken

In Compliance 

Y/N

Repeat 

Recommendation? 

Y/N

8. Ensure safety vulnerabilities are 

corrected.

Ceiling tiles are properly clipped; no 

dirty linen receptacles are in 

unprotected areas; inappropriate 

shower control fixtures were replaced; 

splintered doors have been replaced 

and are maintained; and oxygen tanks 

are properly secured and stored.

Y N

9. Require patient privacy vulnerabilities to be 

corrected.

There are no clipboards or charts 

visible, and there have been no 

incidences of visible patient 

information. Care-trackers have been

installed.

Y N

CPRS Business Rules

10. Ensure CPRS business rules comply with 

VHA policy and Office of Information 

guidance. 

Software informational patch 

USR*1*26 is in place, and we are 

currently up to sequence 32 on the 

package.

Y N

SHEP

11. Require an action plan to be implemented 

to improve patient satisfaction that includes 

measurable goals and assigns responsibility 

for completion of tasks.

An action plan has been implemented 

to improve patient satisfaction. In 

addition, a Planetree coordinator was 

hired to oversee the identified 

opportunities and progress made. This 

information is discussed and shared 

with the VSB and the ECMS.

Y N
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

Appendix C

VA OIG Office of Healthcare Inspections 13

VHA Satisfaction Surveys

VHA has identified patient and employee satisfaction scores as significant indicators of 

facility performance. Patients are surveyed monthly. Table 1 below shows facility,

VISN, and VHA overall inpatient and outpatient satisfaction scores and targets for 

FY 2010. 

Table 1

FY 2010

(inpatient target = 64, outpatient target = 56)

Inpatient 

Score 

Quarter 1

Inpatient 

Score 

Quarter 2

Inpatient 

Score 

Quarter 3

Inpatient 

Score 

Quarter 4

Outpatient 

Score 

Quarter 1

Outpatient 

Score 

Quarter 2

Outpatient 

Score 

Quarter 3

Outpatient 

Score 

Quarter 4 

Facility 33.8 39.6 51.9 48.8 57.6 54.2 54.0 55.0

VISN 67.4 66.1 65.6 70.1 53.4 54.5 56.3 55.7

VHA 63.3 63.9 64.5 63.8 54.7 55.2 54.8 54.4

Employees are surveyed annually. Figure 1 below shows the facility’s overall employee 

scores for 2008, 2009, and 2010. Since no target scores have been designated for 

employee satisfaction, VISN and national scores are included for comparison.
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 14

Hospital Outcome of Care Measures

Hospital Outcome of Care Measures show what happened after patients with certain

conditions14

Table 2 

received hospital care. The mortality (or death) rates focus on whether 

patients died within 30 days of their hospitalization. The rates of readmission focus on 

whether patients were hospitalized again within 30 days. Mortality rates and rates of 

readmission show whether a hospital is doing its best to prevent complications, teach 

patients at discharge, and ensure patients make a smooth transition to their home or 

another setting. The hospital mortality rates and rates of readmission are based on 

people who are 65 and older. These comparisons are “adjusted” to take into account 

their age and how sick patients were before they were admitted to the VA facility. 

Table 2 below shows the facility’s Hospital Outcome of Care Measures for 

FYs 2006–2009. 

Mortality Readmission

Heart Attack Congestive 

Heart 

Failure

Pneumonia Heart Attack Congestive 

Heart 

Failure

Pneumonia

Facility * 11.34 14.44 * 19.81 15.41

VHA 13.31 9.73 15.08 20.57 21.71 15.85

* Not enough cases.

 

14 Congestive heart failure is a weakening of the heart’s pumping power. With heart failure, your body does not get 

enough oxygen and nutrients to meet its needs. A heart attack (also called acute myocardial infarction) happens 

when blood flow to a section of the heart muscle becomes blocked, and the blood supply is slowed or stopped. If 

the blood flow is not restored in a timely manner, the heart muscle becomes damaged from lack of oxygen. 

Pneumonia is a serious lung infection that fills your lungs with mucus and causes difficulty breathing, fever, cough, 

and fatigue.
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

Appendix D

VISN Director Comments 

VA OIG Office of Healthcare Inspections 15

Department of

Veterans Affairs Memorandum

Date: July 19, 2011

From: Director, Veterans in Partnership Network (10N11)

Subject: CAP Review of the Battle Creek VA Medical Center, 

Battle Creek, MI

To: Director, Seattle Office of Healthcare Inspections (54SE) 

Director, Management Review Service (VHA 10A4A4

Management Review)

1. Attached is Battle Creek’s response to the draft report of the Combined 

Assessment Program (CAP) review of the Battle Creek VA Medical 

Center. 

2. If you have any questions, please contact Ms. Kelley Sermak, Acting 

Quality Management Officer at 734-222-4302.

Michael S. Finegan, Director, VISN 11 (10N11)
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

Appendix E

Facility Director Comments

VA OIG Office of Healthcare Inspections 16

Department of

Veterans Affairs Memorandum

Date: July 19, 2011

From: Director, Battle Creek VA Medical Center (515/00)

Subject: CAP Review of the Battle Creek VA Medical Center, 

Battle Creek, MI

To: Director, Veterans in Partnership Network (10N11)

1. I have reviewed the draft report of the Inspector General’s Combined

Assessment Program (CAP) of the Battle Creek VA Medical Center. 

We concur with all the findings and recommendations. 

2. I appreciate the opportunity for this review as a continuing process to 

improve the care to our Veterans. Thank you.

Suzanne M. Klinker
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 17

Comments to Office of Inspector General’s Report

The following Director’s comments are submitted in response to the recommendations 

in the Office of Inspector General report:

OIG Recommendations

Recommendation 1. We recommended that OPPE data be reviewed on an ongoing 

basis and that service-specific competency criteria be approved by the MEC. 

Concur

Target date for completion: Completed April 11, 2011

Service specific competency criteria are included on Professional Practice Evaluations 

(PPE), both Focused and Ongoing, these are approved and monitored by the Service 

and the Executive Committee of the Medical Staff (ECMS). The Ongoing Professional 

Practice Evaluation (OPPE) is being reviewed in a regular basis by the Service and 

ECMS. The credentialing office has met with each Service and coordinated the review 

dates for each provider OPPE. Also, the credentialing office sends Service Chiefs 

notifications and reminders regarding OPPEs up for review.

Recommendation 2. We recommended that all privileges be reviewed to determine 

whether the privileges granted are consistent with the clinical practices of the facility. 

Concur

Target date for completion: Completed April 12, 2011

A review of credentialing and privileging records was completed. As of April 12, 2011, 

Endotracheal Intubation privilege was administratively removed from all seventeen 

providers with this privilege. 

Recommendation 3. We recommended that diagnostic clinicians consistently 

document the time critical results were communicated to ordering providers and that 

ordering providers consistently document patient notification and treatment actions in 

response to critical results.

Concur

Target date for completion: Completed April 29, 2011

Diagnostic clinicians and providers have been re-educated on documentation 

requirements regarding communication of critical test results and treatment actions. 

Immediately following recognition of critical results, the ordering provider is informed by 

direct communication utilizing the write down/read back method, the content and time of 
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 18

this communication is recorded in the medical record. The process is being monitored 

daily by the Radiology Supervisor and reported to the Chief of Staff.

Recommendation 4. We recommended that normal test results be consistently 

communicated to patients within the specified timeframe.

Concur

Target date for completion: Completed April 29, 2011

All clinicians who order diagnostic testing have been provided training on the 

requirements to notify patients of normal test results within 14-days and methods 

available to communicate the information. This is completed during initial orientation 

and is discussed regularly at staff meetings and team meetings. Clinical Services have 

been conducting reviews on randomly selected samples of medical records for each 

provider. 

Recommendation 5. We recommended that the process of communicating test results 

to providers and patients be periodically monitored for effectiveness to ensure 

compliance with VHA and local policies.

Concur

Target date for completion: Completed April 29, 2011

Results of medical records reviews conducted by clinical Services will be presented at 

the Clinical Executive Board (CEB) for review and to recommend corrective actions as 

appropriate; CEB will report results to Executive Leadership Board. This process has 

been initiated, Services will present to CEB in a regular basis. Clinical Services have 

also incorporated timely test results notification in the Focused and Ongoing 

Professional Practice Evaluations (FPPE/OPPE).

Recommendation 6. We recommended that PR findings be discussed at the MEC

quarterly.

Concur

Target date for completion: Completed April 11, 2011

Peer Review level assignment data, action items log and other pertinent information will 

be shared with the Executive Committee of the Medical Staff (ECMS) at least quarterly; 

the process has been initiated and is a regular agenda item.
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 19

Recommendation 7. We recommended that UM Committee reports be discussed at 

the QB quarterly.

Concur

Target date for completion: Completed April 18, 2011

Beginning fiscal year 2011, the Quality Board began review of Utilization Management 

Committee reports and minutes as a standing agenda item, discussed on a quarterly 

basis, and are recorded in the Quality Board minutes. In addition, Utilization 

Management personnel submit daily updates to Leadership during the morning reports. 

Recommendation 8. We recommended that unauthenticated documentation be 

monitored and that processes for addressing identified medical record review problems 

be strengthened.

Concur

Target date for completion: July 30, 2011

A report of unauthenticated medical records documentation will be run twice a week and 

will be addressed with Service Chiefs for completion. Starting at the July 2011 meeting, 

the Medical Records Committee (MRC) will review the reports, corrective actions taken 

and outcomes; this review will become a standing agenda item. Also, at this meeting, 

the MRC will review current tool used by the committee for medical records review. 

Service Chiefs will be asked to present corrective actions taken to address the findings 

of the medical records review process at the MRC meeting following the reporting of 

findings to the Service. 

Recommendation 9. We recommended that infection prevention strategies education 

be provided to patients infected or colonized with MDRO and their families and be 

documented.

Concur

Target date for completion: Completed May 27, 2011

A template progress note (resident/veteran/family education note) was developed and is 

now implemented. Educational materials have been provided to medical unit, inpatient 

mental health, and community living center.

Recommendation 10. We recommended that the required MDRO risk assessments be 

conducted and documented.

Concur

Target date for completion: Completed April 6, 2011
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 20

The risk assessment has been conducted and documented and will be repeated yearly.

Recommendation 11. We recommended that employees receive initial and annual 

MDRO education and that the training be consistently documented.

Concur

Target date for completion: Completed May 13, 2011

MDRO education is provided to employees upon hire at New Employee Orientation and 

annually thereafter. Current employees have the MDRO education module added to 

their annual curriculum and is documented in the Talent Management System.

Recommendation 12. We recommended that staff document patient advance care 

planning using approved progress note titles and link the notes to the CWAD posting.

Concur

Target date for completion: July 29, 2011

Approved progress note titles implemented and linked to CWAD. Staff training on this 

process will be completed by July 29, 2011.

Recommendation 13. We recommended that processes be strengthened to ensure 

that discharge instructions are consistent with current orders and include all required 

elements.

Concur

Target date for completion: Completed June 24, 2011

The Inpatient Discharge Instructions template has been modified to make all elements 

required; clinicians will not be able to complete or sign the note until information is 

entered on all required fields. Since discharge orders will transfer automatically to the 

Inpatient Discharge Instructions template, providers are mandated to review current 

orders at time of discharge to ensure consistency.

Recommendation 14. We recommended that a risk assessment be completed and that 

all fire extinguishers be conspicuously marked, readily accessible, and immediately 

available.

Concur

Target date for completion: September 1, 2011 

A risk assessment addressing the locking of fire extinguishers in cabinets where they 

are subject to physical damage, along with their marking will be completed by the 

medical center’s Fire Service, and coordinated through the medical center’s Safety 

Committee for action as appropriate.
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

VA OIG Office of Healthcare Inspections 21

Recommendation 15. We recommended that radiology department staff complete 

annual radiation safety training and that the training be documented.

Concur

Target date for completion: July 8, 2011

An annual radiation safety training course and test were added to the Talent 

Management System (TMS) and this training was assigned to all radiology department 

employees on May 9, 2011. This training will be recorded and tracked by the Chief, 

Ancillary Services to ensure that all radiology department employees have completed 

this training by July 8, 2011 and annually thereafter. 

Recommendation 16. We recommended that inspection dates be placed on all lead 

shields and aprons.

Concur

Target date for completion: Completed March 31, 2011

On March 31, 2011 inspection dates were placed on all lead shields and aprons. These 

items are periodically reviewed and inspected and the respective date placed on the 

item. 
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

Appendix F

VA OIG Office of Healthcare Inspections 22

OIG Contact and Staff Acknowledgments

Contact For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720

Contributors Karen Moore, RN, Director, Seattle Regional Office, Project 

Leader

Dan Kolb, PhD, Team Leader 

Sami O’Neill, MA, Team Leader

Gail Bozzelli, RN 

Sarah Lutter, RN, JD

Mary Noel Rees, MPA

Marc Lainhart, BS, Program Support Assistant 

John Brooks, Office of Investigations
CAP Review of the Battle Creek VA Medical Center, Battle Creek, MI

Appendix G

VA OIG Office of Healthcare Inspections 23

Report Distribution

VA Distribution

Office of the Secretary

Veterans Health Administration

Assistant Secretaries

General Counsel

Director, Veterans in Partnership Network (10N11)

Director, Battle Creek VA Medical Center (515/00)

Non-VA Distribution

House Committee on Veterans’ Affairs

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies

House Committee on Oversight and Government Reform

Senate Committee on Veterans’ Affairs

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies

Senate Committee on Homeland Security and Governmental Affairs

National Veterans Service Organizations

Government Accountability Office

Office of Management and Budget

U.S. Senate: Carl Levin, Debbie Stabenow

U.S. House of Representatives: Fred Upton

This report is available at http://www.va.gov/oig/publications/reports-list.asp.