Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-00026-146 

Combined Assessment Program
 

Review of the
 

VA Northern Indiana
 

Health Care System
 

Marion, Indiana
 

April 19, 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 VA Northern Indiana Health Care System, Marion, IN 

Glossary 

ALOS average length of stay 

BCC Bedside Care Collaborative 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CEB Clinical Executive Board 

CLC community living center 

COC coordination of care 

CPR cardiopulmonary resuscitation 

CPRS Computerized Patient Record System 

CWAD Crisis, Warning, Allergies and/or Adverse Reactions, 

and Directives 

EOC environment of care 

facility VA Northern Indiana Health Care System 

FY fiscal year 

JC Joint Commission 

MDRO multidrug-resistant organisms 

NCPS National Center for Patient Safety 

OI Office of Information 

OIG Office of Inspector General 

PCSB Patient Care Safety Board 

PI performance improvement 

PR peer review 

QLC Quality Leadership Council 

QM quality management 

RCA root cause analysis 

SARRTP Substance Abuse Residential Rehabilitation 

Treatment Program 

SDS same day surgery 

SHEP Survey of Healthcare Experiences of Patients 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

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
 

Management of Test Results............................................................................. 2
 

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

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

Physician C&P................................................................................................... 5
 

EOC................................................................................................................... 6
 

QM..................................................................................................................... 6
 

Review Activity Without Recommendations............................................................ 7
 

Medication Management ................................................................................... 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................ 13
 

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

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

F. OIG Contact and Staff Acknowledgments ......................................................... 21
 

G. Report Distribution ............................................................................................ 22
 

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

Review of the VA Northern Indiana Health Care System,
 

Marion, IN
 

Review Purpose: The purpose was 

to evaluate selected activities, focusing 

on patient care administration and 

quality management, and to provide 

crime awareness training. We 

conducted the review the week of 

February 7, 2011. 

Review Results: The review covered 

seven activities. We made no 

recommendations in the following 

activity: 

 Medication Management 

The facility’s reported accomplishments 

were its participation in a national 

Bedside Care Collaborative in 2009 and 

2010 and receipt of the Gold 

Cornerstone Award from the National 

Center for Patient Safety in 2010. 

Recommendations: We made 

recommendations in the following six 

activities: 

Management of Test Results: Ensure 

facility policy defines timeframes for 

communicating critical pathology results. 

Ensure diagnostic pathology clinicians 

document communication of critical 

results to ordering providers. 

Communicate normal and critical test 

results to patients, and document the 

communication in the medical record. 

Document patient understanding of 

critical test results in the medical record. 

Coordination of Care: Discuss advance 

care planning with patients, and 

document discussions using approved 

progress note titles. Ensure that 

discharge instructions include all 

required elements and that orders are 

correctly transcribed into discharge 

instructions. 

Management of Multidrug-Resistant 

Organisms: Provide infection prevention 

strategies education to patients infected 

or colonized with multidrug-resistant 

organisms and their families, and 

document the education. 

Physician Credentialing and Privileging: 

Ensure physician clinical privileges are 

setting specific. 

Environment of Care: Identify and 

resolve environmental deficiencies. 

Secure confidential patient information. 

Quality Management: Ensure all 

required items are included in health 

record reviews. Require the health 

record review committee to meet at 

least quarterly. Monitor the copy and 

paste functions. 

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 VA Northern Indiana Health Care System, Marion, IN 

Objectives and Scope
 

Objectives
 

Scope
 

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

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

services. The objectives of the CAP review are to: 

	 Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care administration 

and QM. 

	 Provide crime awareness briefings to increase employee 

understanding of the potential for program fraud and the 

requirement to refer suspected criminal activity to the 

OIG. 

We reviewed selected clinical and administrative activities to 

evaluate the effectiveness of patient care administration and 

QM. Patient care administration is the process of planning 

and delivering patient care. QM is the process of monitoring 

the quality of care to identify and correct harmful and 

potentially harmful practices and conditions. 

In performing the review, we inspected selected areas, 

interviewed managers and employees, and reviewed clinical 

and administrative records. The review covered the 

following seven activities: 

	 COC 

	 EOC 

	 Management of MDRO 

	 Management of Test Results 

	 Medication Management 

	 Physician C&P 

	 QM 

The review covered facility operations for FY 2010 and 

FY 2011 through February 7, 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 VA Northern Indiana 

Health Care System, Fort Wayne and Marion, Indiana, 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

Report No. 07-03185-82, February 25, 2008.) The facility 

had corrected all findings. (See Appendix B for further 

details). 

During this review, we also presented crime awareness 

briefings for 211 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
 BCC	 The facility participated in a national BCC in 2009 and 2010. 

The goal was to optimize inpatient flow and improve 

processes as well as empower clinical care teams to engage 

in continuous quality improvement activities. One objective 

identified in 2009 was to decrease the ALOS for congestive 

heart failure patients by 0.5 days. The facility implemented 

quality improvement processes that resulted in a decrease in 

the ALOS from 6.8 days during quarter 2 of FY 2009 to 

3.2 days by the end of quarter 4 of FY 2010. 

Gold Cornerstone	 In 2010, the facility received the Gold Cornerstone Award 

Award from the NCPS for completing all RCAs in 2009 within the 

45-day timeframe required by VHA. 

Results 

Review Activities With Recommendations 

Management of 

Test Results 

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

review that identified improvement opportunities related to 

documentation of notification of abnormal test results and 

follow-up actions taken.1 

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

reviewed medical records. We identified the following areas 

that needed improvement. 

Policy. VHA requires that facilities develop a written policy 

defining the acceptable length of time between the 

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

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

VA OIG Office of Healthcare Inspections 2 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

availability of critical tests, values, or results and receipt by 

the responsible provider.2 Facility policy did not specify 

reporting timeframes for critical results for non-frozen 

pathology specimens. 

Documentation of Ordering Provider Notification. VHA 

requires that diagnostic pathology clinicians document in the 

medical record the time and means of critical test result 

communication and the name of the ordering provider 

contacted.3 We reviewed the medical records of nine 

patients who had critical results and found that there was 

documentation that the ordering provider was notified in only 

four of the records. 

Communication of Normal and Critical Results. VHA 

requires facilities to communicate normal results to patients 

no later than 14 calendar days from the date that the results 

were available to the ordering provider.4 We reviewed the 

medical records of 20 patients who had normal results and 

found that only 16 of the records contained documented 

evidence that the facility had communicated the results to the 

patients. 

For communications where it is important for the patient to 

quickly take some kind of action, such as a change in 

medication or a return to the facility for further evaluation, 

VHA requires facilities to document that communication was 

received by the patient and understood.5 We reviewed the 

medical records of 29 patients who had critical results and 

found that only 19 of the 29 records contained documented 

evidence that the patients had been notified. 

Recommendations	 1. We recommended that the facility define in policy 

timeframes for communicating critical pathology results. 

2. We recommended that diagnostic pathology clinicians 

consistently document communication of critical results to 

ordering providers. 

3. We recommended that normal and critical test results be 

consistently communicated to patients and documented in 

2 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009.
 3 VHA Directive 2009-019.
 4 VHA Directive 2009-019.
 5 VHA Directive 2009-019.
 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

the medical record and that patient understanding of critical 

test results be documented in the medical record. 

COC	 The purpose of this review was to evaluate whether the 

facility managed advance care planning, advance directives, 

and discharges in accordance with applicable requirements. 

We reviewed patients’ medical records for evidence of 

advance care planning, advance directives, and discharge 

instructions. We identified the following areas that needed 

improvement. 

Advance Care Planning and Progress Note Titles. VHA 

requires that primary care providers discuss advance care 

planning with all patients who have decision-making 

capacity.6 VHA also requires that staff use specific progress 

note titles when documenting advance care planning 

discussions with patients and link these notes to the CWAD 

posting in the electronic medical record. We reviewed 

10 patient records and found documentation of advanced 

care planning discussion or a completed advance care 

document for only 5 of the 10 patients. Additionally, the 

facility used the required progress note titles in only three of 

the five records with advance care planning documentation. 

Discharge Instructions. VHA requires that upon discharge 

from the facility, providers include information regarding 

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

in instructions to patients.7 In addition, The JC requires that 

clinicians provide patients with written discharge instructions. 

We reviewed the medical records of 10 discharged patients 

and found that only 7 of the records addressed all required 

elements. In one record, the diet and activity level 

recommendations were incorrectly transcribed from the 

orders to the discharge instructions. In two records, the diet 

recommendations were not addressed in the discharge 

instructions. 

Recommendations	 4. We recommended that staff discuss advanced care 

planning with all patients and document the discussions 

using approved progress note titles linked to the CWAD 

posting. 

6 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009. 7 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

Management of 

MDRO 

Recommendation 

Physician C&P 

5. We recommended that processes be strengthened to 

ensure that discharge instructions include all required 

elements and that orders are correctly transcribed into the 

discharge instructions. 

The purpose of this review was to evaluate whether the 

facility had developed a safe and effective program to reduce 

the incidence of MDRO in its patient population in 

accordance with applicable requirements. 

We inspected the CLC unit at the Marion campus and a 

medicine unit at the Fort Wayne campus, and we interviewed 

four employees. We identified no deficits in either the 

inspections or staff interviews. However, we identified the 

following area that needed improvement. 

Patient/Family Education. The JC requires that patients 

infected or colonized8 with MDRO and their families receive 

education on infection prevention strategies, such as hand 

washing and the proper use of personal protective 

equipment. We reviewed 16 medical records and found that 

only 10 of the records had documented evidence of MDRO 

education. 

6. We recommended that infection prevention strategies 

education be provided to patients infected or colonized with 

MDRO and their families and be documented. 

The purpose of this review was to determine whether the 

facility had consistent processes for physician C&P that 

complied with applicable requirements. 

We reviewed 11 physicians’ C&P files and profiles and found 

that licenses were current and that primary source 

verification had been obtained. However, we identified the 

following area that needed improvement. 

Setting-Specific Clinical Privileges. VHA requires that clinical 

privileges be specific for each clinical site.9 We found that 

one of the physicians whose profile we reviewed had been 

granted clinical privileges that were not supported by the 

physician’s practice setting. 

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

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

VA OIG Office of Healthcare Inspections 5 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

Recommendation 

EOC 

Recommendations 

QM 

7. We recommended that physician clinical privileges be 

setting specific. 

The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

At the Fort Wayne campus, we inspected the intensive care 

unit, a medical unit, the urgent care area, SDS, the 

cardiopulmonary clinic, and radiology (imaging and nuclear 

medicine). At the Marion campus, we inspected CLC-1B, 

CLC-1C, the SARRTP area, acute mental health, radiology, 

the cardiopulmonary clinic, and occupational therapy. The 

facility maintained a generally clean and safe environment. 

However, we identified the following areas that needed 

improvement. 

Environmental Safety. At the Fort Wayne campus, several 

patient rooms on the medical unit had damaged drywall 

surfaces and peeling paint and cracked plaster around the 

windows. In SDS, we found missing floor tiles in the patient 

recovery area. At the Marion campus, several doorframes 

that provided direct access to the outside had penetrating 

corroded areas with sharp edges. 

Patient Privacy. The Health Insurance Portability and 

Accountability Act requires confidential patient information to 

be secured. In passing admissions desks and nursing 

stations on 13 units we inspected, we observed that on 7 of 

the units, the computer monitors located on these desks and 

stations did not have privacy screens and could be viewed 

by the public. 

8. We recommended that processes be strengthened to 

ensure that environmental deficiencies are identified and 

resolved. 

9. We recommended that processes be strengthened to 

ensure that confidential patient information is secured. 

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 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

documents. We identified the following area that needed 

improvement. 

Health Record Review. VHA requires facilities to conduct 

health record reviews that include specific items, to report 

results to the health record review committee at least 

quarterly, and to monitor the copy and paste functions.10 

The health record review committee provides oversight of the 

review process and analyzes reports. While the facility had 

performed health record reviews, we found that they did not 

include all required items. Additionally, the health record 

review committee did not meet quarterly nor did they receive 

and analyze results. Also, the facility did not monitor the 

copy and paste functions in the electronic medical record. 

Recommendation	 10. We recommended that health record review processes 

be strengthened to ensure that all required items are 

included, that the health record review committee meet at 

least quarterly, and that the copy and paste functions be 

monitored. 

Review Activity Without 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. 

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 15–20 for full text of the Directors’ comments.) We will follow up on the 

planned actions until they are completed. 

10 VHA Handbook 1907.01. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

Appendix A 

Facility Profile11 

Type of Organization Two campus medical facility 

(Fort Wayne and Marion, IN) 

Complexity Level 3 

VISN 11 

Community Based Outpatient Clinics Goshen, IN 

South Bend, IN 

Muncie, IN 

Peru, IN 

Veteran Population in Catchment Area 140,625 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

131 

 CLC/Nursing Home Care Unit 150 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

October 2010) 

$224 

Prior FY (2010) 

$237.3 

 Medical Care Expenditures $23 $236.3 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

1,422 

20,985 

1,124 

1,425 

41,537 

7,220 

o CLC/Nursing Home Care Unit 6,894 45,216 

Hospital Discharges 424 2,423 

Total Average Daily Census (including all bed 

types) 

227.1 227.8 

Cumulative Occupancy Rate (in percent) 80.5 76.5 

Outpatient Visits 60,481 330,937 

11 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Require that assault data is critically 

analyzed when presented to the PI 

Committee. 

Assault data is trended and analyzed 

by the Prevention and Management of 

Disruptive Behavior Committee. Data 

is forwarded to the PI Committee and 

the QLC through the PCSB. 

Y N 

2. Ensure that the facility’s Director takes 

action to meet VHA requirements for PRs. 

Processes have been implemented to 

ensure that all PRs are tracked and 

that potential delinquencies are 

communicated to the reviewer, the 

reviewer’s supervisor, and the Chief of 

Staff. A review of all PRs assigned 

after August 2010 shows 100 percent 

compliance with VHA’s 45- and 

120-day timeframes. 

Y N 

3. Require that patient complaint data is 

critically analyzed and compared to data 

from the SHEP survey and that findings are 

reported to the PI Committee for corrective 

action. 

Patient complaint data is reviewed 

weekly in the Director’s report and 

monthly at the QLC. A revised version 

of the Patient Complaint/SHEP report 

was presented at the December 2010 

QLC meeting. 

Y N 

4. Require that clinically active staff receive 

CPR training in accordance with VHA and 

facility policy. 

A new process has been implemented 

to closely monitor compliance. 

Updated reports are provided quarterly 

to the QLC and the CEB. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

5. Require that contract employees’ 

background investigations are completed in 

accordance with VHA policy. 

Background checks for contract 

providers are required before providers 

report for duty. All contracts and 

copies of updated background checks 

are maintained in the Human Resource 

office. 

Y N 

6. Require that blood usage data is critically 

analyzed for the PI Committee to take 

action. 

Blood usage data is critically analyzed, 

and the information is provided to the 

CEB and the QLC. In addition, a 

Transfusion Utilization Committee has 

been implemented. 

Y N 

7. Take action to establish a collaborative 

disclosure process to ensure that patients are 

informed of their right to file claims. 

The facility implemented the use of the 

standardized CPRS template for 

institutional disclosures that includes 

the right to file a claim. Disclosures are 

monitored by Risk Management and 

reported quarterly to the QLC. A 

review of disclosure notes for 

FYs 2008–2010 shows 100 percent 

compliance. 

Y N 

8. Require that RCAs are completed in 

accordance with VHA and facility policy. 

All RCAs are completed within the 

45-day timeframe as required by VHA 

policy. The facility received the Bronze 

Cornerstone Award in FY 2009 and the 

Gold Cornerstone Award in FY 2010 

from the NCPS for completing RCAs in 

a timely manner. 

Y N 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

EOC 

9. Require that safety vulnerabilities in the 

locked acute mental health unit are 

addressed. 

Mental health EOC rounds are 

conducted quarterly and reviewed by 

the PCSB and the Director. All 

deficiencies are corrected when 

identified. 

Y N 

10. Require that refrigerator temperatures are 

monitored and that corrective actions are 

documented when temperatures are outside 

the acceptable range. Ensure that shower 

curtains are inspected and properly cleaned 

and disinfected. Require that air system vents 

are cleaned. 

Medication refrigerators are centrally 

monitored by pharmacy while nutrition 

refrigerators are centrally monitored by 

dietary supervisors. Warnings are 

received when temperatures vary. 

Supervisors are required to log in 

corrective action(s). 

Environmental Management Service 

has implemented an action plan for 

routine cleaning of shower curtains and 

ceiling vents. Cleanliness is monitored 

through EOC rounds. 

Y N 

11. Require that emergency crash cart 

checks are completed in accordance with 

facility policy and that sharp items are 

secured. 

Emergency crash cart checks are 

monitored by hospital education staff 

and are reported quarterly to the 

Critical Care Committee and the QLC. 

All sharp items are properly secured, 

and sharps safety is monitored monthly 

by the Infection Control Committee. 

Y N 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

CPRS Business Rules 

12. Require that CPRS business rules 

comply with VHA policy and OI guidance. 

Ongoing quarterly reviews and 

monitoring for compliance of business 

rules is done by the Medical Record 

Committee and reported to the CEB. 

Y N 

Follow-Up on Moderate Sedation Practices 

13. Require that contract physicians who 

administer moderate sedation receive 

moderate sedation and CPR training in 

accordance with VHA policy. 

All contract providers have received 

training in accordance with VHA 

policy. 

Y N 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

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 65.1 55.4 62.7 58.7 55.4 56.5 54.8 52.6 

VISN 67.4 66.1 65.6 70.1 53.4 54.5 56.3 55.7 

VHA 63.3 63.9 64.5 63.8 54.7 55.2 54.8 54.4 

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

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

employee satisfaction, VISN and national scores are included for comparison. 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

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

conditions12 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 age 65 and older. These comparisons are “adjusted” to take into 

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

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

FYs 2006–2009. 

Table 2 

Mortality Readmission 

Heart Attack CHF Pneumonia Heart Attack CHF Pneumonia 

Facility 13.13 10.55 14.41 * 21.49 15.96 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

*Not enough cases 

12 Congestive heart failure (CHF) is a weakening of the heart’s pumping power. With heart failure, your body does 

not get enough oxygen and nutrients to meet its needs. A heart attack (also called acute myocardial infarction) 

happens when blood flow to a section of the heart muscle becomes blocked and the blood supply is slowed or 

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

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

fever, cough, and fatigue. 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date: April 7, 2011 

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

Subject: CAP Review of the VA Northern Indiana Health Care 

System, Marion, IN 

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

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

1. Attached, please find NIHCS response to the CAP review. 

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

Quality Management Officer, at 734-222-4302. 

MICHAEL S. FINEGAN 

Attachment 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: April 7, 2011 

From: Director, VA Northern Indiana Health Care System (610/00) 

Subject: CAP Review of the VA Northern Indiana 

System, Marion, IN 

Health Care 

To: Director, Veterans in Partnership (10N11) 

If there is any additional information required, you may contact 

Barbara Lyons, Quality Manager, at 765-674-3321, extension 73344. 

DANIEL D. HENDEE, FACHE
 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

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 the facility define in policy timeframes for 

communicating critical pathology results. 

Concur 

Target date for completion: May 1, 2011 

Facility will revise the local policy in order to define the timeframes for communicating 

critical pathology results. 

Recommendation 2. We recommended that diagnostic pathology clinicians 

consistently document communication of critical results to ordering providers. 

Concur 

Target date for completion: April 30, 2011 

1.	 Chief of Pathology & Laboratory Medicine Service has implemented a process to 

include in the cytology and surgical pathology report documentation the notification 

to the ordering provider. The notation will include the date/time of the notification. 

This will be monitored by laboratory and reported to CEB. 

2.	 If ordering provider/designee cannot be reached within 2 hours of result of a frozen 

section, the provider’s supervisor, service chief, or Chief of Staff in that order until a 

provider is notified. 

Recommendation 3. We recommended that normal and critical test results be 

consistently communicated to patients and documented in the medical record and that 

understanding of critical test results be documented in the medical record. 

Concur 

Target date for completion: June 30, 2011 

A clinical reminder dialog note was developed and providers have been trained on 

telephone and letter notification. 

A system is being developed to automate the printing capability to inform patients of 

normal test results by utilizing the Xerox printers. 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

Recommendation 4. We recommended that staff discuss advanced care planning with 

all patients and document the discussions using approved progress note titles linked to 

the CWAD posting. 

Concur 

Target date for completion: April 30, 2011 

The Nursing Advance Directive Clinical Reminder was updated in February 24, 2011 to 

include expanded options to record need for follow-up by Social Work Service. Social 

Work note was expanded to include reminder for follow-up based on documentation in 

nursing admission note. Social Work will automatically receive a consult based on 

nursing assessment and the need for Social Work intervention. Social workers were 

educated on all updates to advance directives documentation changes 

February 24, 2011. Compliance will be tracked and documented in the Nurse Executive 

Advisory Board. 

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

discharge instructions include all required elements and that orders are correctly 

transcribed into the discharge instructions. 

Concur 

Target date for completion: May 1, 2011 

The interdisciplinary treatment team reviewed the process and implemented the 

procedure where the nursing staff print the physician’s discharge instructions and 

ensure the nursing discharge instructions adhere to the physician instructions. The plan 

is to develop an automated physician discharge note that will automatically upload into 

the nursing discharge instructions. 

Recommendation 6. We recommended that infection prevention strategies education 

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

documented. 

Concur 

Target date for completion: May 31, 2011 

Changes were made January 31, 2011 to the Nursing Patient Information section of the 

assessment to include patient and family education for MDRO. Informatics 

implemented April 1, 2011 a new patient education template that will also include 

MDRO education to the patient and families. Compliance will be tracked and 

documented in Infection Control Committee. 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

Recommendation 7. We recommended that physician clinical privileges be setting 

specific. 

Concur 

Target date for completion: April 30, 2011 

The primary care clinical privilege forms will be modified to be CBOC specific. These 

forms will include only those procedures performed at the CBOCs to eliminate the ability 

to erroneously request a privilege that is not appropriate to that setting. The new form 

will be reviewed and approved by the CEB. 

A 100% review of all CBOC provider privileges will be conducted with the list of 

procedures approved by the CEB. Any discrepancies between the approved list and 

the current granted privileges will be reviewed and administratively corrected by the 

Professional Standards Board with the approval of the CEB. 

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

environmental deficiencies are identified and resolved. 

Concur 

Target date for completion: April 30, 2011 

a.	 Quarterly roundtable meetings will be held with EOC Rounds team members to 

review significant outstanding issues and to provide training and current trending 

to eliminate recurrent findings. This will be tracked through the EOC Board and 

will be initiated by April 15th. 

b.	 A follow-up inspection will be completed 2 weeks after EOC Rounds to ensure 

that corrective actions have been taken. Any remaining open items will be 

tracked monthly through the EOC Board and reported to leadership until 

completed. 

c.	 An updated EOC Rounds checklist that contains common deficiencies will be 

provided to supervisors by April 15th for ongoing departmental inspections. 

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

confidential patient information is secured. 

Concur 

Target date for completion: June 30, 2011 

A comprehensive review of privacy and protection of confidential patient information 

was completed by February 28, 2011. Installation of 50 additional priority placement 

privacy screens was accomplished by March 18, 2011 and repositioning of monitors to 

increase privacy has occurred. Additional privacy screens will be purchased and placed 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

as appropriate by August 31st. This will be monitored during Leadership and EOC 

rounds. 

Recommendation 10. We recommended that health record review processes be 

strengthened to ensure that all required items are included, that the health record 

review committee meet at least quarterly, and that the copy and paste functions be 

monitored. 

Concur 

Target date for completion: May 31, 2011 

The Medical Records Management Committee has been meeting monthly since 

December 2010. The committee monitors the copy and paste functions on an on-going 

basis. A new Chief of Health Information Management Services has been assigned and 

will be working to meet the measures. The data will be reported to CEB. 

VA OIG Office of Healthcare Inspections 20 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact	 Verena Briley-Hudson, NP, Director 

Chicago Office of Healthcare Inspections 

Contributors	 Wachita Haywood, RN, Team Leader 

Lisa Barnes, MSW 

Jody Marquez, RN 

Francis Keslof, MHA 

Lynn Sweeney, MD 

Cheryl Walker, NP 

Judy Brown, Program Support Assistant 

John Brooks, Office of Investigations 

VA OIG Office of Healthcare Inspections 21 
CAP Review of the VA Northern Indiana Health Care System, Marion, IN 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans in Partnership (10N11) 

Director, VA Northern Indiana Health Care System (610/00) 

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: Sherrod Brown, Daniel Coats, Richard G. Lugar, Rob Portman 

U.S. House of Representatives: Dan Burton, Joe Donnelly, Robert E. Latta, 

Mike Pence, Todd Rokita, Marlin Stutzman 

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

VA OIG Office of Healthcare Inspections 22