Department of Veterans Affairs
 

Office of Inspector General
 

Combined Assessment Program
 

Summary Report
 

Management of
 

Multidrug-Resistant Organisms in
 

Veterans Health Administration Facilities
 

Report No. 11-02870-04 October 14, 2011
 VA Office of Inspector General
 

Washington, DC 20420
 
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)
 
Management of Multidrug-Resistant Organisms in Veterans Health Administration Facilities 

Executive Summary
 

The VA Office of Inspector General Office of Healthcare Inspections completed an 

evaluation of the management of multidrug-resistant organisms (MDRO) in Veterans 

Health Administration facilities. The purposes of the evaluation were to determine 

whether facilities (1) complied with Centers for Disease Control and Prevention 

guidelines, the national patient safety goal, and Joint Commission standards regarding 

MDRO, hand hygiene, isolation, and environmental cleanliness and (2) adequately 

communicated about patients infected or colonized with MDRO. 

Inspectors evaluated the management of MDRO at 24 facilities during Combined 

Assessment Program reviews conducted from October 1, 2010, through March 31, 2011. 

Veterans Health Administration facilities recognized the importance of establishing and 

maintaining measures to reduce the incidence of health care-associated infections due to 

MDRO. We identified three areas where compliance with MDRO requirements needed 

improvement. We recommended that the Under Secretary for Health, in conjunction with 

Veterans Integrated Service Network and facility senior managers, ensures that: 

	 Patients infected or colonized with MDRO and their families receive infection 

prevention strategies education, such as hand washing and the proper use of personal 

protective equipment. 

 Facilities provide MDRO education to designated staff during orientation and 

annually thereafter based on risk assessment results. 

 Facilities develop policies and programs that control and reduce antimicrobial agent 

usage. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General

Washington, DC 20420

TO: Under Secretary for Health (10) 

SUBJECT: Combined Assessment Program Summary Report – Management of 

Multidrug-Resistant Organisms in Veterans Health Administration 

Facilities 

Purpose

The VA Office of Inspector General Office of Healthcare Inspections evaluated the 

management of multidrug-resistant organisms (MDRO) in Veterans Health 

Administration facilities. The purposes of the evaluation were to determine whether 

facilities (1) complied with Centers for Disease Control and Prevention guidelines, the 

national patient safety goal, and Joint Commission standards regarding MDRO, hand 

hygiene, isolation, and environmental cleanliness, and (2) adequately communicated 

about patients infected or colonized with MDRO. 

Background

The Centers for Disease Control and Prevention defines MDRO as microorganisms, 

predominantly bacteria, that are resistant to one or more classes of antimicrobial agents. 

MDRO present a serious threat to patients in hospitals. Although there has been much 

emphasis on methicillin-resistant Staphylococcus aureus, other bacteria, such as 

gram-negative organisms (for example, Pseudomonas), Clostridium difficile, and 

vancomycin-resistant enterococci, play a significant role in the morbidity and mortality of 

hospitalized patients. 

As illness acuity has increased, patients also face a risk of developing health 

care-associated infections. Risks include such factors as age, prolonged hospital (or 

nursing home) stays, pressure ulcers, indwelling urinary devices, and multiple or 

prolonged courses of antimicrobial therapy. Each of these, as well as other factors, alter a 

patient’s ability to fight infection. 

VA Office of Inspector General 1 
Management of Multidrug-Resistant Organisms in Veterans Health Administration Facilities 

The Centers for Disease Control and Prevention and The Joint Commission have 

recommended actions to promote the control of MDRO in hospitalized patients. These 

include using effective and consistent hand hygiene practices, educating patients and 

staff, and judiciously using antimicrobial agents. 

Scope and Methodology

Inspectors evaluated the management of MDRO at 24 facilities during Combined 

Assessment Program reviews conducted from October 1, 2010, through 

March 31, 2011. The facilities reviewed represented a mix of size, affiliation, geographic 

location, and Veterans Integrated Service Networks (VISNs). We interviewed selected 

program managers and reviewed documents, including facility self-assessments, patient 

medical records, and training records. We also conducted physical inspections of 

selected patient care units. 

We generated an individual Combined Assessment Program report for each facility. For 

this report, we analyzed and summarized the data from the individual facility Combined 

Assessment Program reviews. 

Inspectors conducted the reviews in accordance with Quality Standards for Inspection 

and Evaluation published by the Council of the Inspectors General on Integrity and 

Efficiency. 

Inspection Results

Issue 1: Patient and Family Education

The Joint Commission’s national patient safety goal1 requires that facilities provide 

education about health care-associated infection prevention strategies to patients who are 

infected or colonized2 with MDRO. Infection prevention education is also important for 

these patients’ family members. 

We reviewed 422 medical records of patients infected or colonized with MDRO, such as 

methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and 

various gram-negative organisms. We found that 157 patients and their families 

(37 percent) did not receive MDRO education. 

We recommended that patients infected or colonized with MDRO and their families 

receive infection prevention strategies education, such as hand washing and the proper 

use of personal protective equipment. 

1 The Joint Commission, “Hospital Accreditation Program, 2010 Chapter: National Patient Safety Goals,” National
 

Patient Safety Goal 07.03.01, performance element 3.

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

VA Office of Inspector General 2 
Management of Multidrug-Resistant Organisms in Veterans Health Administration Facilities 

Issue 2: Staff Education

Facilities conduct periodic risk assessments for MDRO acquisition and transmission. 

Based on the results of these risk assessments, facilities may identify a need for 

designated staff to be educated about health care-associated infections, MDRO, and 

prevention strategies.3 Twenty-one (88 percent) of the 24 facilities identified in their risk 

assessments a need for designated staff to receive MDRO education during orientation 

and annually thereafter. 

We reviewed a total of 463 employee training records from these 21 facilities. Of the 

59 employees hired within the previous 12 months, 13 (22 percent) did not receive 

MDRO education during orientation. Of the 404 employees who had been employed 

more than 12 months, 89 (22 percent) did not receive annual MDRO education. 

We recommended that facilities provide MDRO education to designated staff during 

orientation and annually thereafter based on risk assessment results. 

Issue 3: Antimicrobial Agent Use

The Centers for Disease Control and Prevention recommends review, control, and 

improvement in the use of agents known to perpetuate the incidence of MDRO.4 The 

Infectious Diseases Society of America and the Society for Healthcare Epidemiology of 

America have developed guidelines to reduce the incidence and risk for transmission of 

MDRO.5 The primary goal of antimicrobial stewardship is to optimize clinical outcomes 

while minimizing unintended consequences of antimicrobial use. 

At the time of our review, the Veterans Health Administration did not require its facilities 

to have programs to control and reduce antimicrobial agent use. We understand that a 

task force has been formed and that a draft directive is in progress. Fourteen (58 percent) 

of the facilities in our review had not developed antimicrobial control policies. 

We recommended that the Veterans Health Administration require facilities to develop 

policies and programs that control and reduce antimicrobial agent use. 

Conclusions

We identified strengths in Veterans Health Administration facilities’ management of 

MDRO in the areas of routine risk assessments, dissemination of MDRO-positive patient 

information to relevant clinical staff, and consistent hand hygiene and isolation 

precautions practices. However, compliance with applicable MDRO requirements 

3 The Joint Commission, performance element 2.
 4 Jane D. Siegel, MD, et al., “Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006.”
 5 Timothy H. Dellit, et al., “Infectious Diseases Society of America and the Society for Healthcare Epidemiology of
 

America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship,” Clinical
 

Infectious Diseases, Vol. 44, No. 2, 2007, pp. 159–177.
 

VA Office of Inspector General 3 
Management of Multidrug-Resistant Organisms in Veterans Health Administration Facilities 

needed improvement in the areas of patient and family education, staff education, and 

control of antimicrobial agents. 

Recommendations

Recommendation 1. We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, ensures that patients infected or 

colonized with MDRO and their families receive infection prevention strategies 

education, such as hand washing and the proper use of personal protective equipment. 

Recommendation 2. We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, ensures that facilities provide 

MDRO education to designated staff during orientation and annually thereafter based on 

risk assessment results. 

Recommendation 3. We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, ensures that facilities develop 

policies and programs that control and reduce antimicrobial agent use. 

Comments

The Under Secretary for Health concurred with the findings and recommendations. The 

implementation plan is acceptable, and we will follow up until all actions are completed. 

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 4 
Management of Multidrug-Resistant Organisms in Veterans Health Administration Facilities 

Appendix A

Under Secretary for Health Comments

Department of

Veterans Affairs Memorandum

Date: September 2, 2011
 

From: Under Secretary for Health (10)
 

Subject: OIG Combined Assessment Program Summary Report:
 

Management of Multidrug-Resistant Organisms in Veterans 

Health Administration Facilities (VAIQ 7128023) 

To: Assistant Inspector General for Healthcare Inspections (54) 

1. I have reviewed the draft report and concur with the report’s 

recommendations. Attached is the Veterans Health Administration’s 

(VHA) corrective action plan for the report’s recommendations. 

2. Thank you for the opportunity to review the draft report. If you have 

any questions, please contact Linda H. Lutes, Director, Management 

Review Service (10A4A4) at (202) 461-7014. 

(original signed by:) 

Robert A. Petzel, M.D.
 

Attachment
 

VA Office of Inspector General 5 
Management of Multidrug-Resistant Organisms in Veterans Health Administration Facilities 

VETERANS HEALTH ADMINISTRATION (VHA)

Action Plan

OIG Combined Assessment Program Summary Report: Management 

of Multidrug-Resistant Organisms in Veterans Health Administration 

Facilities (VAIQ 7128023) 

Date of Draft Report: June 21, 2011 

Recommendations/ Status Completion
 

Actions Date_______
 

OIG Recommendations 

Recommendation 1. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, ensures that 

patients infected or colonized with MDRO and their families receive 

infection prevention strategies education, such as hand washing and the 

proper use of personal protective equipment. 

VHA Comments 

Concur 

The Office of the Deputy Under Secretary for Health for Operations and 

Management (DUSHOM) will issue a memorandum to Veterans Health 

Administration (VHA) medical facilities reinforcing the need to provide 

patient/family members with educational brochures that address prevention 

strategies for the transmission of multidrug-resistant organisms (MDRO). 

These materials should include information on hand-washing and use of 

personal protection equipment at minimum. 

In Process Memorandum to be 

issued no later than 

(NLT) 

September 30, 2011 

Recommendation 2. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, ensures that 

VA Office of Inspector General 6 
Management of Multidrug-resistant Organisms in Veterans Health Administration Facilities 

facilities provide MDRO education to designated staff during orientation 

and annually thereafter based on risk assessment results. 

VHA Comments 

Concur 

The DUSHOM will issue a memorandum to the field emphasizing The 

Joint Commission requirements for a risk assessment for MDRO and the 

need for designated staff training at orientation and annually based on the 

results of the risk assessment. 

In Process Memorandum to be 

issued NLT 

October 31, 2011 

The DUSHOM will require each Veterans Integrated Service Network 

(VISN) to submit a list of designated staff positions to be trained as well as 

copies of its risk assessment and training materials to ensure each VISN has 

a plan for oversight. 

In Process To be completed 

NLT 

December 31, 2011 

To address the concerns involving facilities that have not provided the 

training, the DUSHOM will review the Combined Assessment Program 

(CAP) review reports and action plans for the time period of this summary 

report and work directly with the facilities that needed improvement in this 

area to ensure that action plans have been implemented successfully. 

In Process Review to be 

completed NLT 

December 31, 2011 

Recommendation 3. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, ensures that 

facilities develop policies and programs that control and reduce 

antimicrobial agent use. 

VHA Comments 

Concur 

VA Office of Inspector General 7 
Management of Multidrug-resistant Organisms in Veterans Health Administration Facilities 

VHA agrees with the universal need for antimicrobial stewardship 

understanding that the goal is to provide each patient with the appropriate 

antimicrobial at the correct dose and for the proper length of time. 

However, it is important to note that a successful antimicrobial stewardship 

program may not always reduce antimicrobial usage, but it may contribute 

to the national goal of preventing the emergence of antimicrobial resistance. 

To assist VHA facilities in the enhancement of local antimicrobial 

stewardship programs, the Infectious Disease Program Office, in 

conjunction with Pharmacy Benefits Management, both in Patient Care 

Services, conducted three Antimicrobial Stewardship Conferences 

(geographically distributed) in third and fourth quarter fiscal year 2010. 

Completed 

The Deputy Under Secretary for Health for Policy and Services (DUSHPS) 

also chartered the Patient Care Services/Operations and Management 

Antimicrobial Stewardship Task Force in May 2011. The purpose of the 

task force is to optimize the care of Veterans by developing, deploying, and 

monitoring a national-level strategic plan for improvements in 

antimicrobial therapy management. Current activities of the task force 

include the following: 

•	 Establish work groups. Four work groups (Education, Metrics, 

Antimicrobials Tools and Resources, Survey) are to assess 

antimicrobial stewardship resources at local sites. The fifth work 

group will address implementation. 

Completed 

•	 Inventory current antimicrobial stewardship practices in VHA. 

In Process	 Distribution of 

inventory to 

Facilities NLT 

October 31, 2011 

•	 Conduct an educational conference, “Antimicrobial Stewardship in 

VA – Moving Forward.” 

In Process	 Planned for 

November 2011 

VA Office of Inspector General 8 
Management of Multidrug-resistant Organisms in Veterans Health Administration Facilities 

The DUSHPS will work with the DUSHOM to issue an Information Letter 

to VHA medical facilities describing antimicrobial stewardship programs 

and components. 

In Process	 Information Letter 

to be distributed 

NLT 

December 15, 2011 

VA Office of Inspector General 9 
Management of Multidrug-Resistant Organisms in Veterans Health Administration Facilities 

Appendix B

OIG Contact and Staff Acknowledgments

OIG Contact For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720 

Contributors Kathleen Shimoda, RN, Project Coordinator 

Annette Acosta, RN 

Paula Chapman, CTRS 

Audrey Collins-Mack, RN 

Darlene Conde-Nadeau, NP 

Melanie Cool, LD 

Katharine Foster, RN 

Frank Keslof, MHA 

Cathleen King, RN 

JoDean Marquez, RN 

Claire McDonald, MPA 

Jennifer Reed, RN 

Mary Rees, MPA 

Clarissa Reynolds, MBA 

Karen Sutton, BS 

Laura Tovar, LCSW 

Cheryl Walker, NP 

VA Office of Inspector General 10 
Management of Multidrug-Resistant Organisms in Veterans Health Administration Facilities 

Appendix C

Report Distribution
 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

National Center for Patient Safety 

Office of General Counsel 

Office of Medical Inspector 

Veterans Integrated Service Network Directors (1–23) 

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 

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

VA Office of Inspector General 11