Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-00027-162 

Combined Assessment Program
 

Review of the
 

Kansas City VA Medical Center
 

Kansas City, Missouri
 

May 9, 2011
 

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 Kansas City VA Medical Center, Kansas City, MO 

Glossary 

AD advance directive 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CBOC community based outpatient clinic 

CLC community living center 

COC coordination of care 

ECMS Executive Committee of the Medical Staff 

EOC environment of care 

facility Kansas City VA Medical Center 

FPPE Focused Professional Practice Evaluation 

FY fiscal year 

IC infection control 

JC Joint Commission 

LMS Learning Management System 

MDRO multidrug-resistant organisms 

MSDS material safety data sheet 

OIG Office of Inspector General 

OPPE Ongoing Professional Practice Evaluation 

OSHA Occupational Safety and Health Administration 

PPE personal protective equipment 

PSB Professional Standards Board 

QM quality management 

SOPs standard operating procedures 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

Table of Contents
 

Page
 

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

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

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

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

Reported Accomplishments...................................................................................... 2
 

Results ........................................................................................................................ 3
 

Review Activities With Recommendations .............................................................. 3
 

Physician C&P................................................................................................... 3
 

COC .................................................................................................................. 4
 

EOC................................................................................................................... 5
 

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

Management of Test Results............................................................................. 6
 

Review Activities Without Recommendations ......................................................... 7
 

Medication Management ................................................................................... 7
 

QM..................................................................................................................... 7
 

Comments................................................................................................................... 7
 

Appendixes 

A. Facility Profile .................................................................................................... 8
 

B. Follow-Up on Previous Recommendations........................................................ 9
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 11
 

D. VISN Director Comments .................................................................................. 13
 

E. Facility Director Comments ............................................................................... 14
 

F. OIG Contact and Staff Acknowledgments ......................................................... 19
 

G. Report Distribution ............................................................................................ 20
 

VA OIG Office of Healthcare Inspections 
Executive Summary: Combined Assessment Program 

Review of the Kansas City VA Medical Center 

Kansas City, MO 

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 

February 7, 2011. 

Review Results: The review covered 

seven activities. We made no 

recommendations in the following 

activities: 

 Medication Management 

 Quality Management 

The facility’s reported accomplishments 

were the patient safety culture change 

and the Heels’ Angels Campaign. 

Recommendations: We made 

recommendations in the following five 

activities: 

Physician Credentialing and Privileging: 

Ensure Focused Professional Practice 

Evaluations include time periods for 

evaluation and specific criteria. 

Complete Ongoing Professional 

Practice Evaluations according to facility 

policy. Submit actions and 

recommendations for privileging and 

reprivileging to the Executive Committee 

of the Medical Staff, and ensure meeting 

minutes include documentation of 

reviews and decisions. 

Coordination of Care: Update the facility 

policy on advance directives, and 

require designated staff to accurately 

document advance directive notification 

and screening. Provide copies of 

discharge instructions to patients or 

caregivers, and document the provision 

in the medical record. 

Environment of Care: Maintain current 

material safety data sheet information, 

and ensure staff receive training on 

accessing the information electronically. 

Ensure annual bloodborne pathogens 

training and N95 respirator fit testing is 

completed and documented. 

Management of Multidrug-Resistant 

Organisms: Require staff to follow 

facility infection control policy for contact 

precautions. Provide infection 

prevention strategies education to 

patients infected or colonized with 

multidrug-resistant organisms and their 

families, and document the education. 

Management of Test Results: 

Consistently communicate normal test 

results to patients within the specified 

timeframe. 

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
 

VA OIG Office of Healthcare Inspections i 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

Objectives and Scope
 

Objectives
 

Scope
 

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. 

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 seven activities: 

	 COC 

	 EOC 

	 Management of MDRO 

	 Management of Test Results 

	 Medication Management 

	 Physician C&P 

	 QM 

The review covered facility operations for FY 2010 and 

FY 2011 through February 11, 2011, and was done in 

accordance with OIG SOPs for CAP reviews. We also 

followed up on selected recommendations from our prior 

CAP review of the facility (Combined Assessment Program 

Review of the Kansas City VA Medical Center, Kansas City, 

Missouri, Report No. 08-00001-134, May 29, 2008). The 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

facility had corrected all findings. (See Appendix B for 

further details.) 

During this review, we also presented crime awareness 

briefings for 146 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 Accomplishments
 Patient Safety 

Culture Change 

Heels’ Angels 

Campaign 

Staff members at the facility have taken actions to improve 

patient safety after managers identified the need for 

improved communication at all levels of the organization. 

The National Center for Patient Safety recognized the 

facility’s success in changing the culture for patient safety. 

To facilitate the program’s goals, managers strategically 

placed plasma screens throughout the facility that display 

information to promote patient and staff safety; initiated a 

greeter program, mystery shoppers, a shuttle service, and 

improved signage; and developed a log to allow reporting of 

patient safety concerns and provide daily feedback to those 

reporting the concerns. 

The purpose of the Heels’ Angels Campaign is to decrease 

hospital-acquired heel pressure ulcers. The project’s goals 

are to improve quality of patient care and to decrease pain 

and suffering, cost, hospitalizations, infection, amputations, 

and death. Project activities since 2009 include initiating 

mandatory staff skin care classes and utilizing heel lift boot 

decision tree guidelines. 

Since the initiation of the campaign, team leaders report a 

74 percent decrease in heel pressure ulcers. This has 

resulted in significant cost savings to the facility. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

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 11 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. 

FPPE. VHA requires that an FPPE be initiated for all 

physicians who have been newly hired or granted new 

privileges.1 FPPEs must be time-limited and must include 

specific criteria that define the evaluation process. We 

reviewed seven applicable providers’ FPPEs and found that 

only one FPPE documented both time periods for evaluation 

and specific evaluation criteria. 

OPPE. Facility policy requires that data consistent with 

service-specific competency criteria be gathered 

concurrently and reviewed in 6-month intervals by the 

service chief. Although we found sufficient competency data 

to meet current requirements, only 6 of 11 applicable OPPE 

assessments were completed according to facility policy. 

Five assessments were not completed in the required 

timeframe. 

PSB. VHA requires that PSB actions and recommendations 

be submitted to the ECMS.2 ECMS meeting minutes did not 

include documentation of the review or approval of PSB 

privileging or reprivileging recommendations prior to granting 

privileges for the 11 physicians whose folders we reviewed. 

Recommendations	 1. We recommended that processes be strengthened to 

ensure that FPPEs include both time periods for evaluation 

and specific criteria. 

2. We recommended that OPPE assessments be 

completed according to facility policy. 

1 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 2 VHA Handbook 1100.19. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

COC 

Recommendations 

3. We recommended that the PSB submit actions and 

recommendations for privileging and reprivileging to the 

ECMS and that ECMS meeting minutes include 

documentation of reviews and decisions. 

The purpose of this review was to evaluate whether the 

facility managed advance care planning, ADs, and 

discharges in accordance with applicable requirements. 

We reviewed facility policies, and we reviewed patients’ 

medical records for documentation of advance care planning, 

ADs, and discharge instructions. We identified the following 

areas that needed improvement. 

Documentation of AD Notification and Screening. VHA 

requires that facility directors identify the staff responsible for 

conducting AD notification and screening for patients and 

that AD notification and screening are documented in the 

medical record at each admission to a VHA facility.3 Facility 

policy did not designate the staff responsible for providing 

AD notification. We reviewed the medical records of 

10 patients and found no documentation of AD notification. 

Although AD screenings were completed for all patients 

whose records we reviewed, only 6 of the 10 screenings 

were accurate. Four screenings documented that there were 

no ADs; however, we located ADs for those patients in the 

electronic medical records. 

Discharge Instructions. The JC requires that upon discharge 

from a facility, clinicians provide patients with written 

discharge instructions. We reviewed the medical records of 

10 discharged patients and found that 8 records had 

documentation that the patient or caregiver received a copy 

of the discharge instructions. 

4. We recommended that facility policy be updated to 

designate the staff responsible for AD notification and 

screening and that processes be strengthened to ensure that 

designated staff accurately document AD notification and 

screening for patients. 

5. We recommended that processes be strengthened to 

ensure that staff provide copies of discharge instructions to 

3 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

EOC
 

Recommendations 

Management of 

MDRO 

patients or caregivers and document that they provided the 

instructions in the medical record. 

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 inpatient units (medical, surgical, medical and 

surgical intensive care, and locked behavioral health), the 

emergency department, radiology, and outpatient clinics. 

The facility maintained a generally clean and safe 

environment. However, we identified the following conditions 

that needed improvement. 

MSDS Information. OSHA requires that MSDS information 

be available in each clinical area. We inspected eight clinical 

areas and found outdated MSDS hard copies in all areas. In 

addition, staff in only two of the eight clinical areas were 

aware of and could access the electronic MSDS system. 

IC. OSHA requires that all employees receive initial and 

annual training on the OSHA Bloodborne Pathogens Rule. 

We reviewed 20 employee training records and found that 

10 employees had this training documented. 

If facilities use N95 respirators, OSHA requires that 

designated employees are fit tested annually. We reviewed 

23 employee training records and determined that four 

designated employees had the required annual fit testing. 

6. We recommended that current MSDS information be 

maintained and that staff receive training on accessing the 

information electronically. 

7. We recommended that annual bloodborne pathogens 

training and N95 respirator fit testing be completed and 

documented. 

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 reviewed 18 employee MDRO training records and 

interviewed five employees regarding contact isolation and 

cleaning procedures. We identified no deficits. In addition, 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

we inspected medical, surgical, and progressive care units. 

We identified the following areas that needed improvement. 

Contact Precautions. Facility IC policy requires that staff 

follow contact precautions for patients who are colonized or 

infected with MDRO. This includes the use of PPE and 

appropriate hand hygiene. We observed seven facility staff 

who entered contact isolation rooms and found that four 

complied with facility policy on hand hygiene and PPE. 

Patient/Family Education. The JC requires that patients 

infected or colonized4 with MDRO and their families receive 

education on infection prevention strategies, such as hand 

washing and the proper use of PPE. We reviewed 

10 medical records and found that only 6 records had 

documentation of MDRO education. 

Recommendations	 8. We recommended that staff follow facility IC policy for 

contact precautions. 

9. We recommended that infection prevention strategies 

education be provided to patients infected or colonized with 

MDRO and their families and be documented. 

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

Test Results review that identified improvement opportunities related to 

documentation of notification of abnormal test results and 

follow-up actions taken.5 

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

reviewed medical records. We identified the following area 

that needed improvement. 

Communication of Normal Results. VHA requires facilities to 

communicate normal results to patients no later than 

14 calendar days from the date that results were available to 

the ordering provider.6 We reviewed the medical records of 

20 patients who had normal results and found that 

15 of the 20 records contained documented evidence that 

facility staff had communicated results to the patients. 

4 Colonization is the presence of bacteria in the body without causing clinical infection. 

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

Communicating Abnormal Test Results; Report No. 01-01965-24; November 25, 2002.
 6 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009.
 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

Recommendation	 10. We recommended that staff consistently communicate 

normal test results to patients within the specified timeframe. 

Review Activities Without Recommendations
 

Medication	 The purpose of this review was to determine whether the 

Management facility employed safe practices in the preparation, 

transportation, and administration of hazardous medications, 

specifically chemotherapy, in accordance with applicable 

requirements. 

We observed the compounding and transportation of 

chemotherapy medications and the administration of those 

medications in the pharmacy and the chemotherapy clinic. 

We also interviewed staff. We determined that the facility 

safely prepared, transported, and administered the 

medications. We made no recommendations. 

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. The QM program was generally compliant with 

requirements, and senior managers supported the program. 

We made no recommendations. 

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 13–18 for full text of the Directors’ comments.) We will follow up on the 

planned actions until they are completed. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

Appendix A 

Facility Profile7 

Type of Organization Tertiary care medical center 

Complexity Level 1c 

VISN 15 

CBOCs Belton, MO 

Cameron, MO 

Excelsior Springs, MO 

Nevada, MO 

Paola, KS 

Warrensburg, MO 

Veteran Population in Catchment Area 152,718 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

187 

 CLC/Nursing Home Care Unit N/A 

 Other N/A 

Medical School Affiliation(s) University of Missouri-Kansas City 

University of Kansas 

 Number of Residents 92.5 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

December 2010) 

$271 

Prior FY (2010) 

$294 

 Medical Care Expenditures $60 $294 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

1,473 

27,716 

5,490 

1,454 

44,518 

33,989 

o CLC/Nursing Home Care Unit N/A N/A 

Hospital Discharges 1,126 6,805 

Total Average Daily Census (including all bed 

types) 

90 93 

Cumulative Occupancy Rate (in percent) 69.8 72.2 

Outpatient Visits 79,286 474,523 

7 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Complete peer reviews in 120 days. Since the last OIG visit, annual 

completion rates in 120 days have 

improved from 73 percent in FY 2007 

to 96 percent in FY 2008, 99.4 percent 

in FY 2009, and 94 percent after 

3 quarters in FY 2010. We established 

a tighter system of tracking initial 

reviews. 

Y N 

Pharmacy Operations 

2. Secure access for outpatient controlled 

substances storage cabinet. 

The outpatient controlled substance 

storage cabinet has been fitted with an 

electronic system. 

Y N 

3. Conduct weekly nursing inventories of 

automated medication dispensing machines. 

Nurses perform weekly inventories of 

the automated medication dispensing 

machines. Pharmacy conducts a 

weekly run of the Pyxis to ensure that 

nurses are conducting inventories. 

Y N 

EOC 

4. Secure access to supplies, medications, 

utilities, and medical records, and limit access 

to outside contaminants. 

These have been corrected and are 

closely monitored during weekly EOC 

rounds. Noted deficiencies are 

recorded and tracked for prompt 

corrective action. 

Y N 

5. Require designated team members to 

participate on EOC rounds. 

A system has been developed to track 

designated team member participation 

in EOC rounds. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

6. Conduct semi-annual EOC inspections at 

CBOCs. 

CBOC inspections are conducted 

every 6 months to ensure the safety of 

patients, staff, and visitors. 

Y N 

7. Ensure that all locked inpatient psychiatric 

unit staff receive training on environmental 

hazards that pose a threat to suicidal patients. 

All staff on the locked inpatient 

psychiatric unit completed the required 

environmental hazards training. 

Y N 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

Appendix C 

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 60.0 58.2 58.8 55.0 59.8 54.1 52.6 58.7 

VISN 59.0 56.0 56.9 55.2 53.5 52.9 51.6 52.5 

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. 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

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

conditions8 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. 

Table 2 

Mortality Readmission 

Heart Attack CHF Pneumonia Heart Attack CHF Pneumonia 

Facility 13.33 9.73 13.49 20.5 22.25 17.23 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

8 Congestive heart failure (CHF) 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. 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 April 14, 2011 

From:	 Director, VA Heartland Network (10N15) 

Subject:	 CAP Review of the Kansas City VA Medical Center 

Kansas City, MO 

To:	 Director, Kansas City Office of Healthcare Inspections 

(54KC) 

Director, Management Review Service (VHA CO 10B5 Staff) 

I have reviewed the recommendations and concur with the responses and 

action plans. If you have any questions, please contact our office at 

816.701.3000. 

(original signed by:) 

JAMES R. FLOYD, FACHE 

Director, VA Heartland Network (10N15) 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: April 14, 2011
 

From: Director, Kansas City VA Medical Center (589/00)
 

Subject: CAP Review of the Kansas City VA Medical Center,
 

Kansas City, MO 

To: Director, VISN 15 (10N15) 

Attached, please find the responses to the OIG report. 

(original signed by:) 

KENT HILL 

Director, Kansas City VA Medical Center 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

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 processes be strengthened to ensure that 

FPPEs include both time periods for evaluation and specific criteria. 

Concur 

Target date for completion: Recommend this item be closed. 

Timeframes and criteria were discussed with appropriate Service Chiefs and with the 

ECMS. All appropriate Service Chiefs were re-educated. Ongoing monitoring is 

performed by Performance Improvement staff. When FPPEs are received, they are 

reviewed by Performance Improvement staff and Chief of Staff and if not fully completed 

they are returned to the Service Chief. 

Extract from facility credentialing & privileging policy memorandum on FPPE process: 

Focused Practice Evaluation (FPE): Focused Practice Evaluation is a process whereby 

the organization evaluates the privilege-specific competence of the practitioner who 

does not have documented evidence of competently performing the requested privilege 

at the organization, and specifically with all initially requested privileges. This process 

also may be used when a question arises regarding a currently privileged practitioner’s 

ability to provide safe, high quality patient care. Focused professional evaluation is a 

time-limited period during which the organization evaluates and determines the 

practitioner’s professional performance, e.g. 6 months or otherwise designated. Criteria 

for extending the evaluation could be related to lack of sufficient number of cases 

performed during timeframe, questions or concerns that require further evaluation or 

observation. Results and recommendations are provided to the Service Chief who will 

submit to the ECMS. Changes will be implemented to improve performance if indicated. 

Triggers that indicate the need for performance monitoring are clearly defined based on 

single incidents or evidence of a clinical practice trend. 

Recommendation 2. We recommended that OPPE assessments be completed 

according to facility policy. 

Concur 

Target date for completion: Recommend this item be closed. 

There were timeliness issues for service lines who did not complete written 

documentation of their assessments and refer to ECMS timely. Timeliness issues and 

expectations have been discussed at ECMS and with Service Chiefs by the Chief of 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

Staff. OPPEs are to be completed in writing no later than 3 months post evaluation 

period. Performance Improvement staff perform concurrent monitoring for the next two 

consecutive OPPE cycles to assure timely submission and will continue this process as 

required. 

Recommendation 3. We recommended that the PSB submit actions and 

recommendations for privileging and reprivileging to the ECMS and that ECMS meeting 

minutes include documentation of reviews and decisions. 

Concur
 

Target date for completion: Recommend this item be closed.
 

PSB agenda items/actions presented at ECMS. This has been done at ECMS meetings 

subsequent to the OIG visit (March and April 2011) and will be an agenda item each 

month at ECMS. 

Recommendation 4. We recommended that facility policy be updated to designate the 

staff responsible for AD notification and screening and that processes be strengthened 

to ensure that designated staff accurately document AD notification and screening for 

patients. 

Concur 

Target date for completion: June 1, 2011 

Policy revision is currently underway. 

Recommendation 5. We recommended that processes be strengthened to ensure that 

staff provide copies of discharge instructions to patients or caregivers and document 

that they provided the instructions in the medical record. 

Concur
 

Target date for completion: Recommend this item be closed.
 

Policy revised; the section requiring a copy of the discharge instructions in the medical 

record was deleted. Revised policy has been uploaded and staff instructed. 

Discharge Instruction Template was amended on March 1, 2011, to include the 

following statement: “A copy of the discharge instruction given to Patient Family.” 

Ongoing monitoring will occur. 

Recommendation 6. We recommended that current MSDS information be maintained 

and that staff receive training on accessing the information electronically. 

Concur 

Target date for completion: June 30, 2011 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

Current MSDS information to be maintained; thus Safety Officer coordinating with 

Administrative Officers to ensure accurate MSDS inventory is maintained. Staff will be 

given training regarding the electronic MSDS inventory. 

Recommendation 7. We recommended that annual bloodborne pathogens training 

and N95 respirator fit testing be completed and documented. 

Concur 

Target date for completion: June 30, 2011 

Annual bloodborne pathogen training: Service Chiefs review and follow up with staff to 

ensure compliance (annual training completed within a 12-month period). N95 fit testing 

will be completed and documented. 

Recommendation 8. We recommended that staff follow facility IC policy for contact 

precautions. 

Concur 

Target date for completion: Recommend this item be closed. 

Education: 

	 Initial Education: Infection Control Practitioners (ICPs) 

o	 Prepare educational packet: 

 Status: Completed February 9, 2011. 

o	 Provide initial education to areas starting February 10, 2011 through 

March 15, 2011. 

 Status: Completed March 15, 2011. 

 ICPs provided education to all units, offering 28 sessions for 

262 staff. 

o	 ICPs will distribute to Managers the sign in sheets for the in-services 

provided by the ICPs. 

 Status: Completed March 15, 2011. 

 Managers were also provided with the LMS report of staff who 

attended the training. 

 Managers of each area to provide education to any staff not able to 

attend the initial training. 

o	 ICPs will provide a copy of the educational packet to Education so that the 

title can be entered into LMS. 

 Status: Completed February 28, 2011. 

 Face to face, session was created in LMS for Education to enter 

attendance, completed March 15, 2011. 

Monitoring: 

 Acute units will monitor PPE compliance in their units on an ongoing basis and 

report data to the IC Office by the last business day of the month for the reporting 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

month. Service Chiefs will ensure that the monthly data reports provided by the 

IC Office are distributed and discussed at the staff level. 

 Responsible: Nurse Co-leaders, Service Chiefs, Area Managers 

Completion: Process well established. Ensure monthly compliance. 

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: Recommend this item be closed. 

Action: 

	 Re-education: Refresher education presented by Nurse Managers during 

March 2011 regarding the Patient Education Infection Prevention and Control 

template in the electronic medical record. 

o	 Reminder announcement at Executive Committee of Nursing Staff 

meeting March 16, 2011. 

	 Monitor: Associate Director of Patient Care Services to ensure compliance 

with documentation as demonstrated by chart review of five charts per acute 

care unit per month starting April 2011. 

	 Sustain: Additional action plans will be based on findings of the April 2011 

monitor. 

Recommendation 10. We recommended that staff consistently communicate normal 

test results to patients within the specified timeframe. 

Concur 

Target date for completion: September 15, 2011 

In addition to notifying patients of test results face to face during clinic visit and by 

phone, we have also disseminated a letter template to Primary Care Providers to 

facilitate notification of test results. In addition, we are in the process of procuring a 

printer and software, similar to Tampa VA’s program, to facilitate mailing lab results to 

patients on a routine basis. It is our intent to rollout the process facility-wide. 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720 

Contributors Dorothy Duncan, RN, Project Leader 

Reba B. Ransom, RN, Team Leader 

Daniel Kolb, PhD 

Sarah Lutter, RN, JD 

Karen Moore, RN 

Sami O’Neill, MA 

Noel Rees, MPA 

James Seitz, RN 

Laura Tovar, LCSW 

Jennifer Whitehead, Program Support Assistant 

James Werner, Office of Investigations 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the Kansas City VA Medical Center, Kansas City, MO 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Heartland Network (10N15) 

Director, Kansas City VA Medical Center (589/00) 

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: Roy Blunt, Claire McCaskill, Jerry Moran, Pat Roberts 

U.S. House of Representatives: Emanuel Cleaver, Sam Graves, Vicky Hartzler, 

Kevin Yoder 

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

VA OIG Office of Healthcare Inspections 20