Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. --

Combined Assessment Program 

Review of the 

Minneapolis VA Health Care System

Minneapolis, Minnesota

 September 13, 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 Minneapolis VA Health Care System, Minneapolis, MN

VA OIG Office of Healthcare Inspections 

Glossary

AD advance directive

C&P credentialing and privileging

CAP Combined Assessment Program

CLC community living center

COC coordination of care

CPR cardiopulmonary resuscitation

ED emergency department

EN enteral nutrition

EOC environment of care

facility Minneapolis VA Health Care System

FY fiscal year

OIG Office of Inspector General

OSHA Occupational Safety and Health Administration

PI performance improvement

PR peer review

QM quality management

RN registered nurse

VHA Veterans Health Administration

VISN Veterans Integrated Service Network
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

VA OIG Office of Healthcare Inspections 

Table of Contents

Page

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

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

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

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

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

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

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

EOC................................................................................................................... 2

QM..................................................................................................................... 3

COC .................................................................................................................. 5

Physician C&P................................................................................................... 6

Review Activities Without Recommendations ......................................................... 6

EN Safety .......................................................................................................... 6

Management of Workplace Violence................................................................. 7

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

RN Competencies ............................................................................................. 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................ 12

D. VISN Director Comments .................................................................................. 14

E. Facility Director Comments ............................................................................... 15

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

G. Report Distribution ............................................................................................ 20
VA OIG Office of Healthcare Inspections i

Executive Summary: Combined Assessment Program

Review of the Minneapolis VA Health Care System, 

Minneapolis, MN

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 

June 13, 2011. 

Review Results: The review covered 

eight activities. We made no 

recommendations in the following 

activities: 

• Enteral Nutrition Safety

• Management of Workplace Violence

• Medication Management

• Registered Nurse Competencies

The facility’s reported accomplishments 

were having the lowest 30-day mortality 

rates for acute myocardial infarction and 

heart failure among Minnesota hospitals 

and a facility physician who received a 

Veterans Health Administration ethics 

award.

Recommendations: We made 

recommendations in the following four

activities:

Environment of Care: Ensure that 

emergency medications in tackle boxes 

are monitored for expiration dates and 

that expired medications are removed. 

Maintain vaginal speculums in sterile 

packaging until used. Complete annual

bloodborne pathogens training and 

N95 respirator fit testing, and monitor 

compliance. 

Quality Management: Complete all peer 

reviews within the 120-day timeframe or 

have an extension that is approved in 

writing by the facility Director prior to the 

deadline. Ensure moderate sedation 

documentation includes a review of 

current medications and evidence the 

patient was discharged in the company 

of a responsible, designated adult, and 

monitor compliance. Review each 

resuscitation event and analyze all 

required data elements. 

Coordination of Care: Update the facility

advance directive policy to comply with 

Veterans Health Administration policy. 

Provide all components of written 

advance directive notification to 

patients, and document advance 

directive notification and screening in 

the medical record.

Physician Credentialing and Privileging: 

Ensure physician clinical privileges are 

service/setting specific. 

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 Minneapolis VA Health Care System, Minneapolis, MN

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 eight activities:

• COC

• EN Safety

• EOC

• Management of Workplace Violence

• Medication Management

• Physician C&P

• QM

• RN Competencies

The review covered facility operations for FY 2010 and 

FY 2011 through June 13, 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 Minneapolis VA Medical 
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

VA OIG Office of Healthcare Inspections 2 

Center, Minneapolis, Minnesota, Report No. 08-00402-16, 

October 29, 2008). (See Appendix B for further details.) We 

identified one repeat finding in QM. 

During this review, we also presented crime awareness 

briefings for 202 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

Lowest Mortality 

Rates Among

Minnesota 

Hospitals for Two 

Diagnoses 

From July 1, 2007, through June 30, 2010, the Centers for 

Medicare and Medicaid Services’ Hospital Inpatient Quality 

Reporting program compared mortality and readmission 

rates for 132 hospitals in Minnesota. The facility 

demonstrated the lowest rates, which were better than the 

national rates, for acute myocardial infarction and heart 

failure 30-day mortality. Additionally, the facility ranked 

10 out of 125 Minnesota hospitals for acute myocardial 

infarction 30-day readmission and 23 out of 132 hospitals for 

heart failure 30-day readmission.

Physician Received 

VHA Ethics Award

A facility physician, the Co-Director of the CLC, received the 

2010 William A. Nelson Award for Excellence in Health Care 

Ethics. Since 2005, this annual award has recognized an 

individual who has demonstrated a long-term commitment to 

promoting ethical health care practice in VHA through 

excellence, dedication, and accomplishments in the field of 

health care ethics. The physician heads the facility’s Ethics 

Consultative Services and co-chairs the Compliance and 

Integrated Ethics Council.

Results

Review Activities With Recommendations

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 one medical, one surgical, and one CLC unit; 

the medical intensive care, spinal cord injury, polytrauma, 

locked inpatient mental health, and extended care 
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

VA OIG Office of Healthcare Inspections 3 

rehabilitation units; and the ED. We also inspected one 

primary care clinic and the women’s comprehensive health 

clinic. The facility maintained a generally clean and safe 

environment. However, we identified the following conditions 

that needed improvement.

Patient Safety. The Joint Commission requires that expired 

medications be removed and separated from medications 

available for administration. In the spinal cord injury unit, we 

found a tackle box with 14 expired emergency medications. 

Infection Control. Local policy requires that sterilized 

instruments be packaged. We inspected the women’s 

comprehensive health clinic and found two basins of 

unwrapped metal vaginal speculums on the floor in the 

sterile supply room and a tray of unwrapped metal vaginal 

speculums on a shelf in a wall cabinet.

OSHA requires that employees with occupational exposure 

risk receive annual training on the OSHA Bloodborne 

Pathogens Rule. We reviewed 13 employee training records 

and found that 3 employees did not have this training 

documented.

If facilities use N95 respirators, OSHA requires that 

designated employees are fit tested annually. We reviewed 

25 employee training records and determined that 

19 designated employees did not have the required annual fit 

testing.

Recommendations 1. We recommended that processes be strengthened to 

ensure that emergency medications in tackle boxes are

monitored for expiration dates and that expired medications 

are removed.

2. We recommended that vaginal speculums be 

maintained in sterile packaging until used.

3. We recommended that annual OSHA bloodborne 

pathogens training and N95 respirator fit testing be 

completed and that compliance be monitored. 

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.
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

VA OIG Office of Healthcare Inspections 4 

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. Once the need for a PR is determined, VHA requires 

that the final review be completed within 120 days or that an 

extension be requested from and approved in writing by the 

facility’s Director.

1

Moderate Sedation. VHA requires that providers assess 

patients undergoing moderate sedation.

 Four of the PRs initiated from

January 2010 through December 2010 exceeded the 

120-day timeframe. No extensions had been requested for 

two of the PRs, and extensions for the other two had been 

requested and approved after the 120-day deadline. This 

was a repeat finding from the previous CAP review.

2

Resuscitation Outcomes. VHA requires that each facility 

have a policy mandating the membership and responsibilities 

of a CPR committee or its equivalent.

 These 

assessments must include a review of current medications. 

VHA also requires that outpatients who undergo moderate 

sedation are discharged in the company of a responsible, 

designated adult. We reviewed the medical records of 

10 outpatients who underwent moderate sedation and found 

that 5 of the records did not include documentation of a 

review of current medications. These same five records also 

did not contain evidence that the patients were discharged in 

the company of a responsible, designated adult.

3

Recommendations

 Facility policy 

requires that the CPR/Rapid Response Team Subcommittee 

review individual cardiopulmonary arrests occurring at the 

facility and aggregate data to identify and address any 

trends. We found that the subcommittee did not review all 

individual CPR event outcomes nor did it critically analyze 

data from resuscitation episodes to identify trends.

4. We recommended that all PRs be completed within the 

120-day timeframe or have an extension that is approved in 

writing by the facility Director prior to the 120-day deadline.

5. We recommended that processes be strengthened to 

ensure that moderate sedation documentation includes a 

 

1 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010. 2 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2006. 3 VHA Directive 2008-063, Oversight and Monitoring of Cardiopulmonary Resuscitative Events and Facility 

Cardiopulmonary Resuscitation Committees, October 17, 2008.
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

VA OIG Office of Healthcare Inspections 5 

review of current medications and evidence the patient was 

discharged in the company of a responsible, designated 

adult and that compliance is monitored.

6. We recommended that the CPR/Rapid Response Team 

Subcommittee review each resuscitation event and analyze

all required data elements.

COC The purpose of this review was to evaluate whether the 

facility managed advance care planning and ADs in 

accordance with applicable requirements.

We reviewed patients’ medical records for evidence of AD

notification, AD screening, and documentation of advance 

care planning discussions. We also reviewed the facility’s 

policy to determine whether it was consistent with VHA 

policy. We identified the following areas that needed 

improvement.

Facility Policy. VHA requires AD notification and screening 

at each admission to a VHA inpatient facility.4

AD Notification and Screening. VHA requires that patients 

receive written notification at each admission to a VHA 

facility regarding their right to accept or refuse medical 

treatment, to designate a Health Care Agent, and to 

document their treatment preferences in an AD.

 Facility policy 

was not consistent with VHA policy regarding this 

requirement. For example, facility policy directs staff to only 

screen and notify patients if they do not have a documented 

AD linked to the Crisis, Warnings, Allergies and/or Adverse 

Reactions and Directives posting.

5

In addition, VHA requires that staff screen patients at each 

admission to a VHA facility to determine whether they have 

an AD and document the screening in the medical record.

 As part of 

notification, patients must be informed that VA does not 

discriminate based on whether or not they have an AD. We 

reviewed the medical records of 20 patients and found that 

none of the records contained evidence of all components of 

written notification.

6

 

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

 

Facility staff did not document this screening for 18 of 

20 patients whose medical records we reviewed.

5 VHA Handbook 1004.02.

6 VHA Handbook 1004.02. 
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

VA OIG Office of Healthcare Inspections 6 

Recommendations 7. We recommended that the facility AD policy be updated 

to comply with VHA policy.

8. We recommended that processes be strengthened to 

ensure that all components of written AD notification are 

provided to patients and that AD notification and screening 

are documented in the medical record.

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 15 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 area that needed improvement.

Service/Setting-Specific Privileges. VHA requires that 

clinical privileges be service/setting specific for each clinical 

site.

7

Recommendation

 We found that three of the physicians whose profiles 

we reviewed had been granted clinical privileges that were 

not supported by the service or setting where the physicians 

practiced. For example, a provider working in a community 

based outpatient clinic had been granted privileges to 

perform invasive procedures, which the setting did not 

support.

9. We recommended that processes be strengthened to 

ensure that physician clinical privileges are service/setting 

specific. 

Review Activities Without Recommendations

EN Safety The purpose of this review was to evaluate whether the 

facility established safe and effective EN procedures and 

practices in accordance with applicable requirements.

We reviewed policies and documents related to EN and 

patients’ medical records. We also inspected areas where 

EN products were stored while conducting the EOC review, 

and we interviewed key employees. We determined that the 

facility generally met EN safety requirements. We made no 

recommendations.

 

7 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008.
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

VA OIG Office of Healthcare Inspections 7 

Management of 

Workplace 

Violence

The purpose of this review was to determine whether VHA 

facilities issued and complied with comprehensive policy 

regarding violent incidents and provided required training.

We reviewed the facility’s policy and training plan. 

Additionally, we selected three assaults that occurred at the 

facility within the past 2 years, discussed them with 

managers, and reviewed applicable documents. The facility 

had a comprehensive workplace violence policy and 

managed the assaults in accordance with policy. The 

training plan addressed the required prevention and 

management of disruptive behavior training. We made no 

recommendations.

Medication 

Management

The purpose of this review was to determine whether the 

facility employed safe practices in the preparation, transport, 

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 oncology clinic, and we interviewed 

employees. We determined that the facility safely prepared, 

transported, and administered the medications. We made no 

recommendations.

RN Competencies The purpose of this review was to determine whether the 

facility had an adequate RN competency assessment and 

validation process.

We reviewed facility policies and processes, interviewed 

nurse managers, and reviewed initial and ongoing 

competency assessment and validation documents for RNs. 

We determined that the facility had established an effective 

process to ensure that RN competencies were assessed and 

validated and that a plan was in place to take action if 

deficiencies were identified. 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 14–18 for full text of the Directors’ comments.) We will follow up on the 

planned actions until they are completed.
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

Appendix A

VA OIG Office of Healthcare Inspections 8 

Facility Profile8

Type of Organization Tertiary care medical center

Complexity Level 1a

VISN 23

Community Based Outpatient Clinics Cook, MN

Hibbing, MN

Mankato, MN

Maplewood, MN

Rochester, MN

St. James, MN

Chippewa Falls, WI

Hayward, WI

Rice Lake, WI

Superior, WI

Veteran Population in Catchment Area 397,180 (Minneapolis and St. Cloud 

catchment areas)

Type and Number of Total Operating Beds:

• Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program

199

• CLC/Nursing Home Care Unit 80

Medical School Affiliation(s) University of Minnesota

• Number of Residents 653

FY 2011 (through

March 2011) 

Prior FY (2010)

Resources (in millions): 

• Total Medical Care Budget $324.8 $474.7

• Medical Care Expenditures $268.1 $472

Total Medical Care Full-Time Employee 

Equivalents

3,158 3,151

Workload: 

• Number of Station Level Unique 

Patients

69,275 89,087

• Inpatient Days of Care:

o Acute Care 24,642 48,781

o CLC/Nursing Home Care Unit 9,271 22,260

Hospital Discharges 4,209 8,487

Total Average Daily Census (including all bed 

types)

186.3 194.6

Cumulative Occupancy Rate (in percent) 65.4 69.7

Outpatient Visits 381,173 750,485

 

8 All data provided by facility management.
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

Appendix B

VA OIG Office of Healthcare Inspections 9 

Follow-Up on Previous Recommendations

Recommendations Current Status of Corrective Actions 

Taken

In Compliance 

Y/N

Repeat 

Recommendation? 

Y/N

QM

1. Collect and consider provider-specific PI 

data during reprivileging, in accordance with 

VHA policy. 

Provider-specific PI data are collected 

for all privileged medical staff members 

and are reviewed on an ongoing basis 

and at the time of reprivileging.

Y N

2. Complete PRs within the timeframes 

specified in VHA policy, and trend and 

analyze results to identify opportunities for 

improvement. 

Four of the PRs initiated from 

January 2010 through December 2010 

were not completed within 120 days. 

PR results are trended and analyzed to 

identify improvement opportunities. 

N Y (see page 4)

3. Complete root cause analyses within the 

timeframe specified in VHA policy.

Root cause analyses are completed 

within the specified timeframe.

Y N

4. Communicate patient complaint data and 

the resulting PI initiatives to senior 

managers and the Quality Manager, in 

accordance with VHA policy.

The Patient Family Center Director 

presents quarterly reports to the QM 

and Patient Service Councils. The 

Patient Service Council provides 

summaries, which include patient 

complaint data and PI initiatives, to the 

Executive Leadership Board. 

Y N

Pharmacy Operations

5. Require monthly, randomly scheduled 

inspections of all controlled substance 

areas, in accordance with VHA policy. 

The Controlled Substance Coordinator 

developed a schedule to assist in 

randomizing inspections. Inspections 

are monitored monthly by the 

Controlled Substance Leadership 

Workgroup. All inspections have been 

completed through March 2011. 

Y N
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

VA OIG Office of Healthcare Inspections 10

Recommendations Current Status of Corrective Actions 

Taken

In Compliance 

Y/N

Repeat 

Recommendation? 

Y/N

6. Include internal and external notification 

procedures in the facility controlled 

substance policy, in accordance with VHA 

policy. 

Facility policy was updated to reflect 

appropriate adherence to VHA policy to 

assure compliance in notification of 

discrepancies, diversions, and 

suspected thefts.

Y N

Medication Management

7. Require staff to follow facility policy 

regarding medication disposition upon 

admission.

Facility policy was modified, and staff 

were educated on the procedure for 

disposition of medication upon 

admission.

Y N

COC

8. Require staff to complete intra-facility 

transfer assessments within the timeframes 

specified in facility policy.

The Office of Professional Nursing 

Service updated policy on 

January 15, 2009, and provided staff 

education. The policy outlines specific 

timeframes for initial/immediate 

assessments on transfers. Intra-facility 

transfer assessments are completed 

within the required timeframes.

Y N

9. Require provider discharge summaries to 

be consistent with patient discharge orders.

Mental health nurses identified this as 

an opportunity and instituted the 

Discharge Medication Reconciliation 

template specific for Unit 1K. Current 

practice is to use the template and 

follow the appropriate medication 

reconciliation process to ensure 

consistency between discharge 

summaries and discharge orders.

Y N
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

VA OIG Office of Healthcare Inspections 11

Recommendations Current Status of Corrective Actions 

Taken

In Compliance 

Y/N

Repeat 

Recommendation? 

Y/N

EOC

10. Correct identified safety and infection 

control deficiencies.

1. A remote refrigerator monitoring 

system was installed and is functioning 

well.

2. Medications and cleaning supplies 

are secured when not in use.

3. All clean linens are appropriately 

stored.

4. There are designated areas with 

appropriate signage for full and empty 

oxygen tanks.

5. Shatterproof mirrors were installed 

on the locked mental health unit.

Y N

ED Operations

11. Require that patients discharged from the 

ED receive written discharge instructions.

Staff and moonlighters in the ED have

been educated on ED patient 

discharges. Patients are receiving 

appropriate discharge instructions.

Y N

Staffing

12. Take action to ensure managers provide 

the nursing staff required by the established 

staffing methodology.

Nurse managers review hours per 

patient day daily, note when staffing is 

above or below guidelines, and take 

corrective action as indicated. Nurse 

managers and supervisors coordinate 

to staff for unplanned losses. Chief 

nurses review reports weekly and 

make recommendations for change. 

Y N
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

Appendix C

VA OIG Office of Healthcare Inspections 12

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 63.6 67.1 69.5 74.0 54.9 53.7 62.8 53.7

VISN 64.5 63.6 67.4 68.1 56.5 56.9 59.2 57.2

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 Minneapolis VA Health Care System, Minneapolis, MN

VA OIG Office of Healthcare Inspections 13

Hospital Outcome of Care Measures

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

conditions9

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 12.18 7.74 11.22 20.05 19.26 16.05

VHA 13.31 9.73 15.08 20.57 21.71 15.85

 

9

 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 Minneapolis VA Health Care System, Minneapolis, MN

Appendix D 

VISN Director Comments 

VA OIG Office of Healthcare Inspections 14

Department of

Veterans Affairs Memorandum

Date: August 12, 2011

From: Director, VA Midwest Health Care Network (10N23)

Subject: CAP Review of the Minneapolis VA Health Care System, 

Minneapolis, MN

To: Director, Chicago Office of Healthcare Inspections (54CH) 

Director, Management Review Service (VHA 10A4A4

Management Review) 

I have reviewed the findings and recommendations to the OIG CAP 

conducted at the Minneapolis VA Health Care System. I concur with the 

facility response and action plans to the Healthcare Inspection report.

Janet P. Murphy, MBA
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

Appendix E 

Facility Director Comments

VA OIG Office of Healthcare Inspections 15

Department of

Veterans Affairs Memorandum

Date: August 12, 2011

From: Director, Minneapolis VA Health Care System (618/00)

Subject: CAP Review of the Minneapolis VA Health Care System, 

Minneapolis, MN

To: Director, VA Midwest Health Care Network (10N23)

Thank you for the opportunity to review the draft report of 

recommendations from the OIG CAP conducted at the Minneapolis VA 

Health Care System. I have reviewed the report from the site visit that 

occurred during the week of June 13th–17th, 2011. I concur with the 

recommendations and we have already initiated corrective actions.

If you have any questions regarding our responses and actions to the 

recommendations in the report, please contact me at (612) 725.2101.

STEVEN P. KLEINGLASS

Medical Center Director, Minneapolis
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

VA OIG Office of Healthcare Inspections 16

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 

emergency medications in tackle boxes are monitored for expiration dates and that 

expired medications are removed.

Concur

Target date for completion: December 31, 2011

Staff in Spinal Cord Injury Center properly disposed of the noted medications during the 

site visit. A process has been implemented to ensure the emergency medications in the 

tackle boxes are monitored monthly for expiration dates and removed. This will be 

monitored by SCI management monthly for six months and reported out to the 

Executive Committee of the Nursing Staff (ECONS). 

Recommendation 2. We recommended that vaginal speculums be maintained in 

sterile packaging until used. 

Concur

Target date for completion: December 31, 2011

SPD began packaging vaginal speculums individually to ensure proper storage prior to 

utilization during the site visit. Visual checks will be made randomly by SPD to ensure 

that the process is consistent. Audit results will go to the Reusable Medical Equipment 

Committee (RMEC) monthly through December 2011

Recommendation 3. We recommended that annual OSHA bloodborne pathogens 

training and N95 respirator fit testing be completed and that compliance be monitored.

Concur

Target date for completion: December 31, 2011

Policy review will be conducted to ensure that staff requiring annual N95 fit-testing are 

identified, trained and fit-tested. Annual reports of completion will be monitored. OSHA 

blood borne pathogens training will be completed by all appropriate staff, with 

monitoring established through Surveillance, Prevention, and Control of Infection 

Committee (SPCIC) quarterly.
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

VA OIG Office of Healthcare Inspections 17

Recommendation 4. We recommended that all PRs be completed within the 120-day 

timeframe or have an extension that is approved in writing by the facility Director prior to 

the 120-day deadline.

Concur

Target date for completion: December 31, 2011

A process was implemented to ensure all PRs are completed within the 120-day 

timeframe at the time this was noted on the site visit. Requests for Director approved 

extensions are now tracked and monitored quarterly through the Chief of Staff and the

Executive Committee of the Medical Center (ECMS) to ensure compliance.

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

moderate sedation documentation includes a review of current medications and

evidence the patient was discharged in the company of a responsible, designated adult 

and that compliance is monitored.

Concur

Target date for completion: December 31, 2011

Moderate sedation documentation template will be changed to include a review of 

current medications; notation to include discharge in the company of a responsible, 

designated adult; and a chart audit to monitor compliance via Moderate Sedation 

Committee. 

Recommendation 6 . We recommended that the CPR/Rapid Response Team 

Subcommittee review each resuscitation event and analyze all required data elements.

Concur

Target date for completion: December 31, 2011

A process was re-established during the site visit to include a review of each 

resuscitation event by the CPR/Rapid Response Team Subcommittee. Analysis of 

required elements are now tracked, monitored and reported to ECMS on a quarterly 

basis. Reports will be audited to ensure that all required items are present through 

December 2011 through the CPR Committee.

Recommendation 7 . We recommended that the facility AD policy be updated to 

comply with VHA policy.

Concur

Target date for completion: December 31, 2011

The facility AD policy will be reviewed and updated to comply with VHA policy.
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

VA OIG Office of Healthcare Inspections 18

Recommendation 8. We recommended that processes be strengthened to ensure that 

all components of written AD notification are provided to patients and that AD 

notification and screening are documented in the medical record.

Concur

Target date for completion: December 31, 2011

The facility AD policy will be updated to comply with VHA policy to include components 

of written advance directive notification to patients, and document AD notification and 

screening in the medical record. Quarterly audits will be reviewed in Medical Records 

Committee.

Recommendation 9. We recommended that processes be strengthened to ensure that 

physician clinical privileges are service/setting specific.

Concur

Target date for completion: December 31, 2011

Privilege forms used by providers will be revised. These revisions will ensure that only 

privileges appropriate to the setting in which providers are practicing may be granted. 

Privileges granted will be monitored for the next six months to ensure that privileges 

granted are appropriate and setting-specific; compliance will be reported to the ECMS 

at 3 months (October 2011) and 6 months (December 2011).
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

Appendix F 

VA OIG Office of Healthcare Inspections 19

OIG Contact and Staff Acknowledgments

Contact For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720

Contributors Wachita Haywood, RN, Project Leader

Roberta Thompson, LCSW, Team Leader

Lisa Barnes, MSW

Verena Briley-Hudson, ARNP, MN

Elizabeth Burns, MSSW

JoDean Marquez, RN, BSN

Annette Robinson, RN, MSN

Ann Ver Linden, RN, MBA

Judy Brown, Program Support Assistant 

Randy Rupp, Office of Investigations
CAP Review of the Minneapolis VA Health Care System, Minneapolis, MN

Appendix G 

VA OIG Office of Healthcare Inspections 20

Report Distribution

VA Distribution

Office of the Secretary

Veterans Health Administration

Assistant Secretaries

General Counsel

Director, VA Midwest Health Care Network (10N23) 

Director, Minneapolis VA Health Care System (618/00)

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: Al Franken, Ron Johnson, Amy Klobuchar, Herb Kohl

U.S. House of Representatives: Michele Bachmann, Chip Cravaack, Sean P. Duffy, 

Keith Ellison, Ron Kind, John Kline, Betty McCollum

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