Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-01611-250 

Combined Assessment Program
 

Review of the
 

Jesse Brown VA Medical Center
 

Chicago, Illinois
 

August 16, 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 Jesse Brown VA Medical Center, Chicago, IL 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CBOC community based outpatient clinic 

CLC community living center 

ED emergency department 

EN enteral nutrition 

EOC environment of care 

facility Jesse Brown VA Medical Center 

FPPE Focused Professional Practice Evaluation 

FY fiscal year 

IC infection control 

MEC Medical Executive Committee 

MM medication management 

OIG Office of Inspector General 

PRC Peer Review Committee 

QM quality management 

RN registered nurse 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

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
 

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

Physician C&P................................................................................................... 4
 

EOC................................................................................................................... 4
 

EN Safety .......................................................................................................... 5
 

RN Competencies ............................................................................................. 6
 

MM .................................................................................................................... 6
 

Coordination of Care ......................................................................................... 7
 

Review Activity Without Recommendations............................................................ 8
 

Management of Workplace Violence................................................................. 8
 

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

Appendixes 

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

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

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

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

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

F. OIG Contact and Staff Acknowledgments ......................................................... 23
 

G. Report Distribution ............................................................................................ 24
 

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

Review of the Jesse Brown VA Medical Center, Chicago, IL 

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 6, 2011. 

Review Results: The review covered 

eight activities. We made no 

recommendations in the following 

activity: 

 Management of Workplace Violence 

The facility’s reported accomplishments 

were the implementation of an 

employee recognition program, a safe 

patient handling program, a home 

infusion program, and an automated 

hand hygiene tracking system. 

Recommendations: We made 

recommendations in the following seven 

activities: 

Quality Management: Notify the Peer 

Review Committee when corrective 

actions are completed. Ensure Medical 

Record Committee meeting minutes 

accurately address the data presented. 

Monitor the copy and paste functions in 

the electronic medical record. 

Physician Credentialing and Privileging: 

Report Focused Professional Practice 

Evaluation results to the Medical 

Executive Committee. 

Environment of Care: Complete N95 

respirator fit testing, and monitor 

compliance. Ensure all laser users 

complete laser safety training, and 

monitor compliance. 

Enteral Nutrition Safety: Ensure enteral 

nutrition documentation includes all 

required elements, and revise facility 

infection control policy to include enteral 

nutrition infection control expectations. 

Registered Nurse Competencies: 

Ensure that competencies are validated 

annually and that competency validation 

documentation is complete. 

Medication Management: Require staff 

to observe safe work practices when 

handling hazardous drugs in the 

pharmacy compounding area. Ensure 

nursing staff comply with facility 

chemotherapy medication administration 

policy. 

Coordination of Care: Ensure that all 

components of written advance directive 

notification are provided to patients and 

that notification is documented in the 

medical record. 

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 Jesse Brown VA Medical Center, Chicago, IL 

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 eight activities: 

	 Coordination of Care 

	 EN Safety 

	 EOC 

	 Management of Workplace Violence 

	 MM 

	 Physician C&P 

	 QM 

	 RN Competencies 

The review covered facility operations for FY 2010 and 

FY 2011 through June 9, 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 Jesse Brown VA 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

Medical Center, Chicago, Illinois, Report No. 08-00003-10, 

October 17, 2008). The facility had corrected all findings 

from our previous review. (See Appendix B for further 

details.) 

During this review, we also presented crime awareness 

briefings for 342 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
 Employee 

Recognition 

Program 

Safe Patient 

Handling Program 

In 2005, only 508 facility employees participated in the VA All 

Employee Survey. Beginning in 2006, in an effort to improve 

staff involvement and satisfaction, the facility began investing 

2 percent of its annual budget toward employee education, 

awards, and recognition. In addition to a leadership 

development program, the facility offered personal and 

professional development courses. It also hosted an annual 

employee award and recognition ceremony in the summer 

and a dinner dance during the holiday season. Transparent 

leadership became the standard, and employees were 

informed of decisions affecting the facility. In 2010, more 

than 1,600 employees completed the All Employee 

Survey—a response rate of 85 percent. The facility’s overall 

employee scores for 2008, 2009, and 2010 exceeded VISN 

and national scores. (See Appendix C, Figure 1 for further 

details.) 

In 2008, the facility implemented a safe patient handling 

program to reduce the risk of injury to employees while 

enhancing patient safety. Multiple ceiling lifts were installed 

throughout the facility, including in all inpatient units and in 

the ED and procedure areas. In areas where ceiling lifts 

were prohibited, such as psychiatry, staff used auxiliary safe 

patient equipment. Staff received ongoing training and 

competency assessments, and 40 inpatient unit leaders 

provided onsite training and coaching. In FY 2010, the 

facility reported a lifting/repositioning injury rate that was 

lower than the national average. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

Home Infusion 

Program 

Automated Hand 

Hygiene Tracking 

System 

In March 2009, the facility implemented a multi-disciplinary 

home infusion program designed for patients to receive 

intravenous antibiotics and total parenteral nutrition at home. 

Prior to the program’s implementation, patients were either 

admitted to the CLC or placed in community nursing homes 

to complete their treatment. For the past 25 months, more 

than 150 patients have been sent home on antimicrobial 

therapy and total parenteral nutrition. The program has 

saved the facility nearly 4,000 days of hospitalization, which 

is equivalent to $4.2 million in cost savings. Additionally, the 

program has decreased length of stay, increased inpatient 

bed availability, and improved patient satisfaction. 

The facility reported to us that it was the first VA facility to 

implement an automated system to track hand hygiene 

practices. The system tracks hand-washing practices prior 

to patient contact using a series of wall-mounted sensors in 

patient care areas and individualized electronic identification 

badges. It also sends out an alarm to remind employees 

who have not washed their hands. IC practitioners are 

optimistic that information gathered from this system will 

identify patterns of infection transmission and areas in need 

of improvement. 

Results 

Review Activities With 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. We identified the following areas that needed 

improvement. 

Peer Review. VHA requires that the PRC receive notification 

upon completion of corrective actions.1 In 5 of the 13 cases 

reviewed, we found that PRC meeting minutes did not 

indicate that corrective actions had been completed. 

Medical Record Review. VHA requires facilities to conduct 

medical record reviews that include specific areas of review 

and to monitor the copy and paste functions.2 We found that 

1 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010.
 2 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006.
 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

Medical Record Committee meeting minutes reflected data 

that appeared to be unrelated to the conclusions and 

recommendations. For example, the facility reported varying 

monthly compliance rates for verbal orders. However, the 

corresponding conclusions and recommendations did not 

correlate with the data presented for 8 of the 10 months of 

meeting minutes reviewed. In addition, the facility did not 

consistently monitor the copy and paste functions in the 

electronic medical record. 

Recommendations	 1. We recommended that the PRC be notified when 

corrective actions are completed. 

2. We recommended that Medical Record Committee 

meeting minutes accurately address the data presented. 

3. We recommended that processes be strengthened to 

ensure consistent monitoring of the copy and paste 

functions. 

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 16 physicians’ C&P files and profiles and found 

that licenses were current and that clinical privileges held 

elsewhere had been verified. However, we identified the 

following area that needed improvement. 

FPPE. VHA requires reporting of FPPE results to the MEC 

for consideration in making the recommendation on 

privileges for newly hired physicians.3 For three of the six 

newly hired physicians whose profiles we reviewed, we 

found that FPPE results had not been reported to the MEC. 

Recommendation	 4. We recommended that processes be strengthened to 

ensure that FPPE results are reported to the MEC. 

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 selected inpatient (acute medical-surgical, 

mental health, intensive care, CLC, and telemetry) units, the 

same day surgery and post-anesthesia care units, primary 

care and women’s health care clinics, and the ED. The 

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

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

facility maintained a generally clean and safe environment. 

However, we identified the following conditions that needed 

improvement. 

N95 Respirator Fit Testing. If facilities use N95 respirators, 

the Occupational Safety and Health Administration requires 

that designated employees are fit tested annually. We 

reviewed 43 employee training records and determined that 

30 (70 percent) designated employees did not have the 

required annual fit testing. 

Laser Safety. Local policy requires that all laser users be 

trained on the proper and safe use of such equipment. None 

of the 10 employee training records we reviewed had 

documented evidence of this training for FY 2010. 

Recommendations	 5. We recommended that N95 respirator fit testing be 

completed and that compliance be monitored. 

6. We recommended that laser safety training be 

completed and that compliance be monitored. 

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 identified the 

following areas that needed improvement. 

EN Documentation. VHA requires that staff document 

specific EN information in patients’ medical records.4 We 

reviewed the medical records of 10 patients (5 CLC and 

5 acute care) receiving EN and determined that 5 records did 

not contain all required information. For example, none of 

the five records included documentation of gastric residual 

checks. 

EN IC Policy. VHA requires that facility IC policy address 

EN.5 We reviewed facility IC policy and determined that it 

did not address IC expectations for EN, such as swabbing 

4 VHA Handbook 1109.05, Specialized Nutritional Support, May 10, 2007. 5 VHA Handbook 1109.05 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

Recommendations 

RN Competencies 

Recommendation 

MM 

the tops of EN cans with alcohol wipes before pouring 

contents into feeding bags. 

7. We recommended that processes be strengthened to 

ensure that EN documentation includes all required 

elements. 

8. We recommended that facility IC policy be revised to 

include EN IC expectations. 

The purpose of this review was to determine whether the 

facility had an adequate RN competency assessment and 

validation process. 

We reviewed facility policy and processes, interviewed nurse 

managers, and examined initial and ongoing competency 

assessment and validation documents for 12 RNs. We 

identified the following area that needed improvement. 

Competency Validation Documentation. The Joint 

Commission and facility nursing policy require that nursing 

personnel are competent to function in their assignments. 

Core competencies, such as use of standard precautions, 

are skills required for all RNs. Unit/position competencies 

are specific to a particular area of patient care, such as an 

intensive care unit. According to facility policy, competencies 

must be validated annually. Six of the 12 RN competency 

folders were deficient. Four did not contain evidence that 

annual core and unit/position-specific competencies had 

been validated, and three had incomplete or missing 

validation documentation. 

9. We recommended that processes be strengthened to 

ensure that competencies are validated annually and that 

competency validation documentation is complete. 

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 of two chemotherapy 

medications and the transportation and administration of one 

chemotherapy medication in the infusion clinic, and we 

interviewed employees. We identified the following area that 

needed improvement. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

Safe Work Practices. The American Society of 

Health-System Pharmacists requires safe handling of 

hazardous drugs to minimize contamination and ensure staff 

and patient safety. Staff must change gloves whenever they 

exit and re-enter the biological safety cabinet and must wear 

clean gloves when handling the final preparation. In the 

pharmacy compounding area, the supervising pharmacist 

appropriately used clean gloves when labeling and placing 

the final preparations into the transport bag. However, we 

observed a pharmacy technician with unclean gloves holding 

the final preparations during labeling and exiting the 

biological safety cabinet and re-entering without changing 

gloves. 

Facility chemotherapy administration policy requires two RNs 

to verify a chemotherapy medication to ensure that the label 

is consistent with the order. Additionally, one of the RNs 

must record the information in the electronic medication 

administration system prior to administration. We observed 

an RN and a pharmacist rather than two RNs verify a 

medication. Also, the RN did not record the information in 

the medication administration system. 

Recommendation	 10. We recommended that safe work practices be observed 

when handling hazardous drugs in the pharmacy 

compounding area and that processes be strengthened to 

ensure that nursing staff comply with facility policy when 

administering chemotherapy medication. 

Coordination of 

Care 

The purpose of this review was to evaluate whether the 

facility managed advance care planning and advance 

directives in accordance with applicable requirements. 

We reviewed 20 patients’ medical records for evidence of 

advance directive notification, advance directive 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 

area that needed improvement. 

Advance Directive Notification. 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 advance 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

directive.6 As part of notification, patients must be informed 

that VA does not discriminate based on whether or not they 

have an advance directive. None of the 20 records reviewed 

contained evidence of all components of written notification. 

Recommendation	 11. We recommended that processes be strengthened to 

ensure that all components of written advance directive 

notification are provided to patients and that notification is 

documented in the medical record. 

Review Activity Without Recommendations 

Management of The purpose of this review was to evaluate whether VHA 

Workplace facilities issued and complied with comprehensive policy 

regarding violent incidents and provided required training. Violence 

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. 

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

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 15–22 for full text of the Directors’ comments.) We will follow up on the 

planned actions until they are completed. 

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

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

Appendix A 

Facility Profile7 

Type of Organization Tertiary care medical center 

Complexity Level Clinical referral Level 1-A facility 

VISN 12 

CBOCs Lakeside CBOC, Chicago, IL 

Auburn Gresham CBOC, Chicago, IL 

Chicago Heights CBOC, Chicago Heights, 

IL 

Adam Benjamin, Jr. VA Outpatient Clinic, 

Crown Point, IN 

Veteran Population in Catchment Area 810,000 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

188 

 CLC/Nursing Home Care Unit 22 

 Other 0 

Medical School Affiliation(s) Northwestern University, Feinberg School 

of Medicine 

University of Illinois at Chicago College of 

Medicine 

 Number of Residents 201 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

March 31, 2011) 

$183.3 

Prior FY (2010) 

$355.0 

 Medical Care Expenditures $182.3 $374.5 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

2,172.9 

34,940 

24,094 

2,130.7 

43,193 

47,595 

o CLC/Nursing Home Care Unit 2,517 3,932 

Hospital Discharges 4,064 8,930 

Total Average Daily Census (including all bed 

types) 

133.94 130.61 

Cumulative Occupancy Rate (in percent) 79 76 

Outpatient Visits 267,291 560,604 

7 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations 

QM 

Current Status of Corrective Actions 

Taken 

In Compliance Repeat 

Recommendation? 

Y/N 

1. Implement a process for the use of N

relevant provider-specific performance 

information to assess competency and to 

support privileging decisions. 

C&P process requirements are 

documented in Professional Standards 

Board meeting minutes. 

Provider-specific information from 

Ongoing Professional Practice 

Evaluation and FPPE processes is 

used to support decisions, and 

information is documented in 

Professional Standards Board monthly 

committee meeting minutes. 

Y 

2. Require that committee minutes 

document meeting attendance and 

discussion to support C&P decisions. 

Professional Standards Board meeting 

minutes document attendance and 

discussion that supports C&P 

decisions. 

Y N 

3. Require that C&P folders and all C&P 

documentation meet VHA and legal 

requirements. 

C&P folders and documentation 

comply with VHA and legal 

requirements. 

Y N 

4. Ensure that all peer reviews meet the 

timeliness requirements and that providers 

review all cases meeting the criteria 

specified in local policy. 

MM 

The PRC meets monthly. Peer 

reviews are tracked in a database to 

ensure timeliness and completion as 

indicated in local policy. 

Y N 

5. Require that nurses consistently N

document the effectiveness of all pain 

medications within the required timeframe of 

the local policy. 

Reassessments are conducted and 

documented within the required 

timeframe per local policy. 

Y 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance Repeat 

Recommendation? 

Y/N 

ED Operations 

6. Ensure that ED staff complete 

inter-facility transfer documentation, as 

required by VHA policy. 

ED staff use electronic informed 

consent to complete inter-facility 

transfer documentation. Medical 

record reviews for the past 3 years 

show good documentation. 

Y N 

Coordination of Care 

7. Ensure that staff consistently complete 

intra-facility transfer documentation, as 

required by local Nursing Service policy. 

Nursing staff use electronic informed 

consent to complete inter-facility 

transfer documentation, as required by 

Nursing Service policy. Documentation 

shows quality medical record review 

over a 3-year period. 

Y N 

8. Ensure that staff consistently complete 

discharge documentation, as required by 

local policy. 

Discharge instructions are completed 

and monitored as required by local 

policy. The Medical Record Committee 

reports discharge documentation data 

to the MEC on an ongoing basis. 

Y N 

EOC 

9. Require staff to check emergency carts, 

as required by local policy. 

Emergency carts are checked and 

monitored as required by local policy. 

Y N 

10. Require staff to monitor refrigerators, as 

required by local policy. 

All facility and CBOC refrigerators are 

tracked electronically using the Temp 

Trac monitoring system, as required by 

local policy. 

Y N 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance Repeat 

Recommendation? 

Y/N 

11. Ensure that suicide prevention posters 

and brochures are displayed in highly visible 

areas throughout the facility. 

Suicide Prevention posters and 

brochures can be seen throughout the 

facility and are placed in high-risk 

areas. The Suicide Prevention 

Coordinator consistently ensures the 

presence of the posters and brochures. 

Y N 

12. Require that staff update the local hand 

hygiene policy to include the process for 

monitoring health care workers’ adherence 

to required hand hygiene practices and that 

staff consistently collect hand hygiene 

compliance data for all direct patient contact 

areas. 

Hand hygiene policy has been 

updated. Hand hygiene practices are 

continuously monitored and reported to 

the IC Committee, which reports to the 

Quality Leadership Council quarterly. 

The annual IC risk assessment 

includes the required hand hygiene 

elements. 

Y N 

13. Ensure that staff conduct EOC rounds 

weekly and inspect all facility areas at least 

semi-annually. 

EOC rounds are conducted weekly, 

and all areas are inspected 

semi-annually. EOC rounds are 

tracked, reported, and documented in 

Safety Committee meeting minutes. 

Y N 

14. Require staff to develop action plans for 

EOC deficiencies. 

EOC deficiencies, including action 

plans, are tracked, reported, and 

documented in Safety Committee 

meeting minutes. 

Y N 

15. Require that all staff who work on the 

locked inpatient psychiatric unit receive 

training on environmental hazards that pose 

a threat to suicidal patients. 

All inpatient psychiatric unit staff 

receive training on environmental 

hazards annually. Training compliance 

is tracked electronically. 

Y N 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

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 60.2 50.3 48.6 66.9 55.6 53.6 49.7 53.0 

VISN 62.0 64.9 65.1 68.4 55.5 58.6 54.0 56.9 

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. 

0.0 

0.5 

1.0 

1.5 

2.0 

2.5 

3.0 

3.5 

4.0 

4.5 

5.0 

2008 2009 2010 

Facility 

VISN 

National 

VA ALL EMPLOYEE SURVEY 

OVERALL SATISFACTION Figure 1: 

LEVEL OF SATISFACTION 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

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 Congestive 

Heart 

Failure 

Pneumonia Heart Attack Congestive 

Heart 

Failure 

Pneumonia 

Facility 12.39 8.16 14.32 21.42 22.45 17.73 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

8 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. 

VA OIG Office of Healthcare Inspections 14 
N Director Comments

tions

011

irector,

iew of the

ent Review)

P report regarding Jesse Brown

ns and the

M.D.

nter, Chicago, IL

V

Office of Healthcare Inspe

Veterans Affai

,

CAP Re Center

Director, Division

10A4A4

Manage

I have reviewed the C d

with all recommendati

Murawsky,

Jesse Brown VA Medical

Memorandu

Jesse Brown VA Medical

Healthcare Inspections

Management Review Service (VHA

VAMC a

submitted

CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: July 25, 2011
 

From: Network Director, VISN 12 (10N12)
 

Subject: CAP Rev 

Chicago, 

view of the Jesse Brown VA Medical 

IL 

Center, 

To: Director, 

(54LA) 

Los Angeles Healthcare Inspections Division 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

I have reviewed the CAP report regarding Jesse Brown VAMC and concur 

with all recommendations and the proposed action plan submitted. 

Jeffrey A. Murawsky, M.D. 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: July, 25, 2011
 

From: Director, Jesse Brown VA Medical Center (537/00)
 

Subject: CAP Review of the Jesse Brown VA Medical Center,
 

Chicago, IL 

To: Network Director, VISN 12 (10N12) 

Jesse Brown VA Medical Center concurs with the eleven OIG 

recommendations and provides the attached action plan to address all 

recommendations. Thank you. 

(original signed by:) 

Michael Anaya, Director 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

Comments to Office of Inspector General’s Report
 

The Director submitted the following comments in response to the recommendations in 

the Office of Inspector General report: 

OIG Recommendations 

Recommendation 1. We recommended that the PRC be notified when corrective 

actions are completed. 

Concur 

Target date of implementation/completion: August 31, 2011 

Planned Action: The Peer Review Committee utilizes the facility’s meeting minute 

format for tracking open items. While the meeting minute format has been utilized for 

over two years, emphasis has been placed on tracking open items to completion. 

Tracking open items is accomplished by placing all open items on the follow-up section 

of the agenda until action plans are completed, reported and documented in the 

meeting minutes. Prior to April 2011, action plans were being tracked but not until 

closure: this methodology will ensure this is completed. Another measure put into place 

is the inclusion of the peer review meeting minutes within the practitioner file when the 

action is identified and closure of the actions. 

Recommendation 2. We recommended that Medical Record Committee meeting 

minutes accurately address the data presented. 

Concur 

Target date of implementation/completion: September 30, 2011 

Planned Action: The Medical Record Committee reviewed the Medical Record 

Committee Charter on June 23, 2011. This assessment assisted in review of the 

Medical Record Committee requirements and the identification of the expected 

outcomes. In addition, the process of addressing agenda items was revised to ensure 

documentation in the meeting minutes which include: discussion/conclusion, 

recommendations/actions, an assignment of responsible parties and when and where 

follow-up reporting will occur until the closure of the issue. When an issue is identified 

and then closed, the complete documentation will be recorded in the meeting minutes to 

notate the compliance or evidence/reasoning for the closure. 

Medical Record Committee follow-up items will be reviewed and followed at each 

meeting with succinct documentation. The meeting minute’s agenda will include the 

methodology of notation under “Follow-Up” of agenda items and all unclosed issues 

from previous meeting minutes. We have also reinforced the process of ensuring that 

all recommended agenda items are reported from the Medical Records Committee to 

the Medical Executive Committee for further discussion and approval/disapproval of 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

recommendations. This information will be reported back to the Medical Record 

Committee for implementation and/or further follow-up by the Chairman of the Medical 

Records Committee post reporting to the Medical Executive Committee. Evidence of 

these events will be noted in the recording of medical record committee minutes. 

Recommendation 3. We recommended that processes be strengthened to ensure 

consistent monitoring of the copy and paste functions. 

Concur 

Target date of implementation/completion: September 30, 2011 

Planned Action: Copy & paste monitoring is aggregated monthly and reported to the 

Medical Records Committee. All clinical services continue to participate in a definitive 

manner by monitoring monthly the copy & paste functions. A clinical report includes the 

monthly data outcome and trending over time. In addition each service will identify any 

adverse trends, or concerns on documented action plan format. Copy and paste 

statistics will be graphed in a cumulative format, based on quarterly reporting and 

monthly data gathering. Our threshold for compliance with the copy & paste process is 

95%. The Copy and Paste Monitor is a standing monthly monitor and is reported by the 

Chairman of the Medical Records Committee to the Medical Executive Committee. 

The Health Information Management Department has begun random audits on copy & 

paste process for all clinical services. These audits will be correlated with the monthly 

clinical services reports provided to the Medical Record Committee. If the results 

identify opportunities for improvement, the clinical service will identify actions through an 

action plan to improve compliance. This will be documented in the Medical Record 

Committee meeting minutes from the initiation of the action plan until compliance is 

achieved. 

The Medical Record Committee and Health Information Management department will 

continue to work toward a collaborative effort of educating our providers on guidelines of 

copy and paste according to local and VHA Health Information Management policy. 

Supplemental educational material will be provided and reviewed at the Medical Record 

Committee assist the clinical representatives address provider education. 

Recommendation 4. We recommended that processes be strengthened to ensure that 

FPPE results are reported to the MEC. 

Concur 

Target date of implementation/completion: August 31, 2011. 

Planned Action: The Professional Standards Board/Medical Executive Committee has 

implemented an extensive process for full compliance with documentation of the 

committee’s review of the FPPE/OPPE prior to OIG review. Although it was noted that 

3 of the 6 newly hired physicians were not reported to MEC, these discrepancies were 

prior to the implementation of the new format of review, discussion and documentation 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

of the FPPE. The Chief of Staff is confident that this process will mandate the review of 

the FPPE results with documentation in the meeting. The COS also reviews all 

information prior to the PSB/MEC. In addition, the Associate Chief of Staff for Clinical 

Affairs conducts quarterly reviews of the individual services OPPE after the initial FPPE. 

Recommend that this recommendation be closed based on the current practice and 

compliance review. 

Recommendation 5. We recommended that N95 respirator fit testing be completed 

and that compliance be monitored. 

Concur 

Target date of implementation/completion: September 30, 2011 

Planned Action: It was noted during the review that our tracking system for Respirator 

fit testing did not retain historical data for tracking of Respirator fit testing. In May 2011, 

a contractor conducted a mass fit test operation to bring the program to full compliance. 

During the OIG review, when the request was made to provide the proof of 2010 fit test 

dates, the results weren’t fully available due to the new fit test records superseding the 

old records in the Microsoft Access Database. The action plan to resolve this 

discrepancy is as follows. In conjunction with Employee Health and Infection Control, 

the Industrial Hygiene/GEMS Coordinator is working to create a new system and obtain 

quantitative fit test (QNFT) equipment that retains the historical data. Additionally, a risk 

assessment was completed to identify the number of personnel requiring fit tests and 

determined that the number of personnel requiring fit testing was dramatically reduced. 

The plan is to train personnel at Jesse Brown and the Community Based Outpatient 

Clinic’s using the new equipment and designate once a week fit testing days to 

accommodate all shifts. Employee data will be tracked via an excel spreadsheet 

exported from QNFT equipment and Service Chiefs will be notified in advance, of their 

employees coming due in their upcoming birth month. Service Chiefs will also be 

notified ahead of time from a monthly report identifying who was delinquent, due to any 

unforeseen circumstances. Employees shall be notified and scheduled for next fit test 

day to ensure no future delinquencies in the program. The current policy lists 

Engineering Services as the tracker for the Respiratory Protection Program, however, 

the program status and compliance reports will be tracked in the Green Environmental 

Systems and Environment of Care Committee, monthly. The projected program 

implementation date is August 24, 2011 and all delinquencies, if any, made current by 

September 16, 2011. 

Recommendation 6. We recommended that laser safety training be completed and 

that compliance be monitored. 

Concur 

Target date of implementation/completion: September 30, 2011 

Planned Action: The Laser Safety Program memorandum was approved 

May 20, 2011 which outlines the laser safety training requirements. The Laser Safety 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

Committee has been chartered May 20, 2011 and will be responsible for monitoring the 

laser safety training compliance for Jesse Brown Medical Center. All Laser Safety 

training will be submitted and included in the TMS training files for database tracking. 

The Laser Safety Committee will report to the Medical Executive Committee quarterly 

the current level of compliance with the laser safety training and any action plans for 

noncompliance with this directive. 

Recommendation 7. We recommended that processes be strengthened to ensure that 

EN documentation includes all required elements. 

Concur 

Target date of implementation/completion: September 30, 2011 

Planned Action: An interdisciplinary group composed of Nursing, Food & Nutrition 

Service, Pharmacy, Computerized Patient Record System (CPRS), and Performance 

Improvement determined the most effective and efficient method to comply with this 

requirements of this program. It was determined that a CPRS template was the 

appropriate and practical action to implement. The template includes the nutritional 

appetite, nothing by mouth (NPO), a section on tube feeding with route, formula 

(type/rate/amount), type of administration (pump/gravity), section for gastric residual 

volume and with general parameters of when to notify MD, and other nutritional support 

(central/peripheral line). Final approval and education of staff on the usage is planned 

for July 30, 2011. 

To ensure sustainability, and continued compliance, five (5) medical records, or 100%, 

per month will be monitored for 3 months to ensure appropriate documentation is 

recorded in the medical record. Any deficiencies noted will require immediate 

notification of the appropriate clinical service and follow-up action plans. The Medical 

Record Review will be reported to the Nutrition Committee. The Nutrition Committee 

reports to the Medical Executive Committee quarterly. 

Recommendation 8. We recommended that facility IC policy be revised to include EN 

IC expectations. 

Concur 

Target date of implementation/completion: August 31, 2011 

Planned Action: The JBVAMC Infection Control Plan is being revised to include the 

prevention of healthcare associated infections (HAI), related to EN and parental 

nutrition. In addition, a memorandum, “Enteral and Parental Nutrition: Special Infection 

Prevention Measures,” was developed and reflects the current expectations regarding 

EN and parental nutrition. This memorandum will be referenced in the Infection Control 

Plan and available on the JBVA web-site, by July 30, 2011. 

The Infection Control and Prevention Committee will monitor surveillance monthly of 

healthcare associated infections related to enteral and parental nutrition. This review 

VA OIG Office of Healthcare Inspections 20 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

will be a standing agenda item for the Infection Control and Prevention Committee to 

address, update, and follow-up any issues identified in Enteral and Parental Nutrition 

Safety. 

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

competencies are validated annually and that competency validation documentation is 

complete. 

Concur 

Target date of implementation/completion: August 31, 2011 

Planned Action: Employee folders will be reviewed monthly by the Nursing 

Competency Review Team for completeness and accuracy. A total of 30 employee 

folders from all nursing units/departments will be reviewed monthly for a compliance 

rate of 90%. The nursing competency review will be presented to the Human 

Resources Committee monthly. 

Recommendation 10. We recommended that safe work practices be observed when 

handling hazardous drugs in the pharmacy compounding area and that processes be 

strengthened to ensure that nursing staff comply with facility policy when administering 

chemotherapy medication. 

Concur 

Target date of implementation/completion: August 31, 2011 

Planned Action: After a comprehensive risk assessment using accepted industry 

regulations including the Unites States Pharmacopeia 797 (USP 797), American Health 

Systems Pharmacists (ASHP) and National Institute for Occupational Safety and Health 

(NIOSH) standards, the pharmacy service has developed a program to accomplish the 

safe handling of chemotherapeutic agents. This risk assessment included a thorough 

evaluation of preparation, labeling and transportation of chemotherapeutic agents. In 

order to meet and exceed the standards, pharmacy technicians change gloves when 

exiting the biological cabinet prior to re-entry. Additionally, the verifying pharmacist 

affixes the labels and places tamper evident buttons for all chemotherapeutic 

preparations. This process will be randomly validated on a monthly basis via direct 

observation. These monthly audits are maintained and will be used for validation of 

performance for each pharmacy personnel compounding chemotherapy. 

Two nurses check the chemotherapy prior to administration and document this double 

check in CPRS. The primary nurse will sign the note and the co-signer will be the 

second nurse. Random monitoring will be completed by Nursing Service and reported 

to the Quality Leadership Council for three months. 

VA OIG Office of Healthcare Inspections 21 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

Recommendation 11. We recommended that processes be strengthened to ensure 

that all components of written advance directive notification are provided to patients and 

that notification is documented in the medical record. 

Concur 

Target date of implementation/completion: August 31, 2011 

Planned Action: The current inpatient advance directive template is being amended to 

include the following statement to meet full compliance of components of the written 

advance directive notification: “the patient was informed that the VA does not 

discriminate based on whether or not they have an advance directive.” 

VA OIG Office of Healthcare Inspections 22 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

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	 Daisy Arugay, MT, Project Leader 

Douglas Henao, RD, Team Leader 

Paula Chapman, CTRS 

Simonette Reyes, RN 

Kathleen Shimoda, RN 

Mary Toy, RN 

Julie Watrous, RN 

John Brooks, Office of Investigations 

VA OIG Office of Healthcare Inspections 23 
CAP Review of the Jesse Brown VA Medical Center, Chicago, IL 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Great Lakes Health Care System (10N12) 

Director, Jesse Brown VA Medical Center (537/00) 

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: Richard J. Durbin, Mark Kirk 

U.S. House of Representatives: Danny K. Davis; Luis Gutierrez; Jesse L. Jackson, Jr.; 

Daniel Lipinski; Mike Quigley; Bobby L. Rush; Jan Schakowsky 

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

VA OIG Office of Healthcare Inspections 24