Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 10-02993-70 

Combined Assessment Program
 

Review of the
 

John D. Dingell VA Medical Center
 

Detroit, Michigan
 

January 21, 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 John D. Dingell VA Medical Center, Detroit, MI 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CBOC community based outpatient clinic 

CHF congestive heart failure 

CLC community living center 

COC coordination of care 

CPRS Computerized Patient Record System 

ED emergency department 

EOC environment of care 

facility John D. Dingell VA Medical Center 

FTE full-time employee equivalents 

FY fiscal year 

HLC Healthcare Leadership Committee 

ICU intensive care unit 

JC Joint Commission 

MDRO multidrug-resistant organisms 

MICU medical intensive care unit 

OIG Office of Inspector General 

OSHA Occupational Safety and Health Administration 

PET positron emission tomography 

PPE personal protective equipment 

PR peer review 

PRC Peer Review Committee 

PRRTP Psychosocial Residential Rehabilitation Treatment 

Program 

QLC Quality Leadership Committee 

QM quality management 

RCA root cause analysis 

SOPs standard operating procedures 

UM utilization management 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Table of Contents 

Page
 

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

Objective and Scope.................................................................................................. 1
 

Objective................................................................................................................. 1
 

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

Reported Accomplishment........................................................................................ 2
 

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

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

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

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

QM..................................................................................................................... 4
 

Management of Test Results............................................................................. 5
 

Medication Management ................................................................................... 5
 

Management of MDRO...................................................................................... 6
 

COC .................................................................................................................. 7
 

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

Appendixes 

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

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

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 15
 

D. VISN Director Comments .................................................................................. 17
 

E. Facility Director Comments ............................................................................... 18
 

F. OIG Contact and Staff Acknowledgments ......................................................... 26
 

G. Report Distribution ............................................................................................ 27
 

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

Review of the John D. Dingell VA Medical Center, Detroit, MI 

Review Purpose: The purpose was 

to evaluate selected activities, focusing 

on patient care administration and 

quality management. We conducted the 

review the week of November 15, 2010. 

Review Results: The review covered 

seven activities. The facility’s reported 

accomplishment was its Lung Cancer 

Collaborative that improved cancer care 

for patients and received the Excellence 

Award in January 2010 from the 

Veterans Health Administration Cancer 

Care Collaborative Planning Committee. 

Recommendations: We made 

recommendations in the following seven 

activities: 

Environment of Care: Maintain 

medication security, secure sharp items 

and cleaning supplies, respond quickly 

to the emergency call system on the 

locked behavioral health unit, and 

secure confidential patient information. 

Complete and document annual 

bloodborne pathogens training and 

N95 respirator fit testing. 

Physician Credentialing and Privileging: 

Ensure that privileges appropriately 

indicate the setting where they may be 

practiced. 

Quality Management: Document peer 

review actions and follow-up in Peer 

Review Committee meeting minutes. 

Include all required components in 

moderate sedation documentation. 

Management of Test Results: 

Communicate normal test results to 

patients within the specified timeframe. 

Medication Management: Adhere to 

American Society of Health-System 

Pharmacists guidelines for preparation 

and administration of hazardous drugs. 

Provide waste containers large enough 

to accommodate all personal protective 

equipment. 

Management of Multidrug-Resistant 

Organisms: Provide infection prevention 

strategies education to patients infected 

or colonized with multidrug-resistant 

organisms and their families and 

document it. Provide annual 

multidrug-resistant organisms education 

to employees and document it. 

Coordination of Care: Conduct advance 

directive notification and screening in 

accordance with Veterans Health 

Administration policy. Include education 

for diet restrictions in discharge 

instructions. 

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. 

 (original signed by:)

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections i 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Objective and Scope 

Objective 

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 objective of the CAP review is to: 

 Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care administration 

and QM. 

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 November 15, 2010, and was done in 

accordance with OIG SOPs for CAP reviews. We also 

followed up on selected recommendations from our prior 

CAP review of the facility (Combined Assessment Program 

Review of the John D. Dingell VA Medical Center, Detroit, 

Michigan, Report No. 07-03184-77, February 19, 2008). The 

facility had corrected all findings. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

enough to be monitored by the OIG until corrective actions 

are implemented. 

Reported Accomplishment 

Lung Cancer
 

Collaborative
 

The facility’s system redesign team identified and focused on 

improving seven processes that would improve cancer care 

for patients: (1) surgery timing, (2) timeliness of ordered PET 

scans, (3) PET scan completion, (4) customer satisfaction, 

(5) type of surgical resection, (6) lung nodule/cancer 

suspicion project, and (7) palliative care for advanced stage 

lung cancer. As a result of the improvements, cancer care is 

timely, patients have fewer appointments, and patient 

satisfaction has increased. In January 2010, the facility 

received the Excellence Award from VHA’s Cancer Care 

Collaborative Planning Committee. 

Results 

Review Activities With Recommendations 

EOC	 The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

We inspected the surgery (A4N), MICU/telemetry (A2N), 

CLC (A6S), medicine (A3N), behavioral health (B2N), and 

geriatrics/rehabilitation (A5S) units; the Firm D primary care 

clinic; and the ED. The facility maintained a generally clean 

and safe environment. However, we identified the following 

conditions that needed improvement. 

Medication Security. JC standards require all medications to 

be secured from access by unauthorized persons. On the 

surgery and geriatrics/rehabilitation units, we found the 

medication room doors open, and no staff were present. On 

the medicine unit, we found unsecured medications in two 

occupied patient rooms, in a PPE rack outside of an 

occupied isolation room, and in the pocket of a rolling 

computer cart. Additionally, in the primary care clinic, we 

found unsecured medication in an examination room. 

Safety. Sharp items and cleaning products must be secured 

when not in use. On the medicine unit, we found unsecured 

syringes and needles in two occupied patient rooms, in the 

pocket of two rolling computer carts, and in the pocket of a 

cart that houses the electrocardiogram machine. 

VA OIG Office of Healthcare Inspections 2 
Recommendations 

CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Additionally, in the ED, we found unsecured needles in an 

unlocked cabinet next to an occupied patient bed. 

We observed unsecured cleaning supplies underneath the 

kitchen sink in the CLC dining room and in the unlocked 

soiled utility room in the ED. 

Staff must be prepared to provide quick responses to 

emergency call systems. We activated the emergency call 

system in an occupied room on the locked behavioral health 

unit. Although staff on the unit heard the alarm, there was a 

delayed response. 

Patient Privacy. The Health Insurance Portability and 

Accountability Act requires confidential patient information to 

be secured. On the MICU/telemetry and medicine units, in 

the primary care clinic, and in the ED, we found unsecured 

documents that displayed patients’ full names, social security 

numbers, and health information. Additionally, on the 

medicine unit, we found an unattended computer displaying 

patient information, and in the ED, we found two computers 

that did not have privacy screens. 

Training. OSHA requires that all employees receive initial 

and annual training on the OSHA Bloodborne Pathogens 

Rule. We reviewed 15 employee training records and found 

that only 13 (87 percent) employees had this training 

documented. 

OSHA requires that staff identified to wear an N95 respirator 

undergo initial and annual fit testing. We requested annual 

fit testing training records for 25 selected employees. We 

found that annual fit testing had not been conducted. 

1. We recommended that processes be strengthened to 

ensure that medication security is maintained. 

2. We recommended that sharp items and cleaning 

supplies be secured at all times. 

3. We recommended that processes be strengthened to 

ensure quick responses to the emergency call system on the 

locked behavioral health unit. 

4. We recommended that processes be strengthened to 

ensure that confidential patient information is secured. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

5. We recommended that annual bloodborne pathogens 

training and N95 respirator fit testing be completed and 

documented. 

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 12 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. 

Privileges. VHA requires that when a facility grants a 

physician privileges to practice, the facility must determine 

whether the privileges should be restricted to specific care 

settings (such as the surgery suite, the ICU, or an outpatient 

clinic) and grant the privileges accordingly.1 Of the 12 C&P 

files we reviewed, 8 (67 percent) documented the granting of 

specialized privileges; however, specific care settings had 

not been appropriately identified. For example, five 

providers had been granted specialized privileges to perform 

invasive procedures, which required certain staffing and 

equipment support, in several settings, including the 

outpatient behavioral health clinic. 

Recommendation	 6. We recommended that privileges appropriately indicate 

the setting where they may be practiced. 

QM	 The purpose of this review was to evaluate whether the 

facility had a comprehensive QM program in accordance with 

applicable requirements and whether senior managers 

actively supported the program’s activities. 

We interviewed senior managers and QM personnel, and we 

evaluated policies, meeting minutes, and other relevant 

documents. The QM program was generally compliant with 

requirements, and senior managers supported the program. 

We identified the following areas that needed improvement. 

PR. VHA requires actions/recommendations for Level 3 PRs 

to be followed to closure.2 We did not find documentation of 

actions and follow-up in PRC meeting minutes. 

1 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 2 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Moderate Sedation. VHA requires that staff privileged to 

provide moderate sedation assess and monitor patients 

undergoing moderate sedation.3 We reviewed the medical 

records of 11 patients who had moderate sedation and found 

that 3 (27 percent) of the records did not include 

documentation of organ systems, airway assessment, 

re-evaluation immediately prior to the procedure, and 

assessment of risk. 

Recommendations	 7. We recommended that PR actions and follow-up be 

documented in PRC meeting minutes. 

8. We recommended that moderate sedation 

documentation includes all required components. 

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

Test Results review that identified improvement opportunities related to 

documentation of notification of abnormal test results and 

follow-up actions taken.4 

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

reviewed medical records. We identified the following area 

that needed improvement. 

Communication of Normal Results. VHA requires facilities to 

communicate normal results to patients no later than 

14 calendar days from the date that the results were 

available to the ordering provider.5 We reviewed the medical 

records of 19 patients who had normal results and found that 

only 11 (58 percent) of the 19 records contained documented 

evidence that the facility had communicated the results to the 

patients. 

Recommendation	 9. We recommended that normal test results be 

consistently communicated to patients within the specified 

timeframe. 

Medication	 The purpose of this review was to determine whether the 

Management facility employed safe practices in the preparation, transport, 

and administration of hazardous medications, specifically 

chemotherapy, in accordance with applicable requirements. 

3 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2010.
 4 Healthcare Inspection Summary Review – Evaluation of Veterans Health Administration Procedures for
 

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

VA OIG Office of Healthcare Inspections 5 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

We observed the compounding and transportation of 

chemotherapy medications and the administration of those 

medications in the oncology clinic, and we interviewed 

employees. We identified the following areas that needed 

improvement. 

Administration and Preparation. The American Society of 

Health-System Pharmacists recommends that gloves be 

sanitized with 70 percent alcohol or other appropriate 

disinfectant before performing any aseptic compounding 

activity. This step was omitted during our observation of the 

compounding phase. Additionally, it is recommended that a 

plastic-backed absorbent pad be placed under the 

administration area to absorb leaks and prevent drug contact 

with patient skin during medication administration. This step 

was omitted during our observation of the medication 

administration phase. 

Waste Disposal. The American Society of Health-System 

Pharmacists requires that hazardous waste containers and 

container openings be large enough to accommodate all 

PPE without pushing or forcing. We noted that the 

hazardous waste container in the pharmacy compounding 

area was utilized for sharps and potentially contaminated 

materials, such as previously worn gowns and gloves. The 

waste disposal container in the oncology clinic was utilized 

for sharps, intravenous administration sets, and potentially 

contaminated materials, such as previously worn gowns and 

gloves. The openings of the waste containers were too 

small, requiring personnel to push PPE through narrow 

openings. 

Recommendations	 10. We recommended that personnel adhere to American 

Society of Health-System Pharmacists guidelines for 

preparation and administration of hazardous drugs. 

11. We recommended that hazardous waste containers be 

provided that are large enough to accommodate all PPE 

without pushing or forcing. 

Management of 

MDRO 

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 medicine (A3N) and surgery (A4N) units 

and interviewed employees and identified no deficits in either 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Recommendations 

COC 

the inspections or staff interviews. However, we identified 

the following areas that needed improvement. 

Patient/Family Education. The JC requires that patients 

infected or colonized6 with MDRO and their families receive 

education on infection prevention strategies, such as hand 

washing and the proper use of PPE. We reviewed 

10 medical records and found that 7 (70 percent) of the 

records did not have documented evidence of MDRO 

education. 

Employee Training. The JC requires that facilities conduct a 

risk assessment to determine the need for staff education. 

The facility’s most recent risk assessment stated that staff 

education was indicated for all employees annually. We 

reviewed 12 employee training records to determine whether 

MDRO education had been provided in accordance with the 

risk assessment. We found that 6 (50 percent) of the 

records reviewed did not have documentation of annual 

MDRO education. 

12. We recommended that infection prevention strategies 

education be provided to patients infected or colonized with 

MDRO and their families and be documented. 

13. We recommended that employees receive annual 

MDRO education and that the training is consistently 

documented. 

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 Directive Notification Documentation. VHA requires 

that patients be given written notification stating their right to 

accept or refuse medical treatment, to designate a health 

care agent, and to document their treatment preferences in 

an advance directive.7 We reviewed 10 patients’ medical 

6 Colonization is the presence of bacteria in the body without causing clinical infection.
 7 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009.
 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

records and found that only 4 (40 percent) had notification 

documented. 

Advance Directive Screening. VHA requires that patients be 

asked whether they want more information about advance 

directives and/or assistance in completing the advance 

directive forms.8 We reviewed 10 patients’ medical records 

and found that only 8 (80 percent) patients had been 

screened. 

Discharge Instructions. VHA requires that providers include 

information regarding medications, diet, activity level, and 

follow-up appointments in patient discharge instructions.9 

We reviewed the medical records of 10 discharged patients 

and found deficiencies in 3 (30 percent) of the records. The 

patients were discharged with diet restrictions; however, we 

did not find documentation that patients or caregivers 

received education regarding these restrictions. 

Recommendations	 14. We recommended that managers ensure that advance 

directive notification and screening are conducted in 

accordance with VHA policy. 

15. We recommended that processes be strengthened to 

ensure that discharge instructions include education for diet 

restrictions. 

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 17–25, for the full text of the Directors’ comments.) We will follow up on 

the planned actions until they are completed. 

8 VHA Handbook 1004.02.
 9 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006.
 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Appendix A 

Facility Profile10 

Type of Organization Tertiary care medical center 

Complexity Level 1c 

VISN 11 

CBOCs Pontiac, MI 

Yale, MI 

Veteran Population in Catchment Area 295,186 

Type and Number of Total Operating Beds: 

 Hospital, including PRRTP 50 

 CLC/Nursing Home Care Unit 102 

Medical School Affiliation Wayne State University 

 Number of Residents 76 

Current FY (through 

August 2010) 

Prior FY (2009) 

Resources (in millions): 

 Total Medical Care Budget $272.3 $261.1 

 Medical Care Expenditures $271.7 $261.1 

Total Medical Care FTE 1,737.2 1,762.5 

Workload: 

 Number of Station Level Unique 

Patients 

41,806 41,204 

 Inpatient Days of Care: 

o Acute Care 25,313 26,609 

o CLC/Nursing Home Care Unit 26,053 26,613 

Hospital Discharges 4,667 4,648 

Total Average Daily Census (including all bed 

types) 

71.5 72.7 

Cumulative Occupancy Rate 61.5% 67.3% 

Outpatient Visits 391,124 420,148 

10 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Take actions to meet VHA requirements 

for PRs. 

PRs are completed within the 

established timeframes, and PRC 

minutes are submitted monthly to the 

Clinical Care Committee/Medical 

Executive Committee and the QLC. 

Y N 

2. Ensure the patient advocate conducts 

critical analyses of patient complaint data, 

and present results to the HLC for action. 

Patient advocates conduct critical 

analyses of patient complaint data, and 

results are presented monthly to the 

Customer Service Steering Committee 

and quarterly to the QLC for action. 

Y N 

3. Conduct an independent review of the 

11 patients cited in the review as having 

adverse outcomes to ensure that VHA policy 

is followed. 

Completed at the time of the previous 

CAP review site visit. 

Y N 

4. Require staff to inform the patients 

identified by our review and/or their 

representatives of their rights to file a claim. 

Templates for clinical and institutional 

disclosures were created and are now 

in use. Completed templates are 

forwarded to the risk manager to 

ensure notification of right to file a tort 

claim and to ensure appropriate 

follow-up review. All of the patients 

and/or their families were appropriately 

contacted. There is documented 

evidence of facility representatives’ 

communication regarding their rights to 

file claims. 

Y N 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

5. Immediately initiate and complete the 

three patient incident reports that were never 

initiated. 

Actions were completed during the 

previous CAP review. Patient incident 

reports were completed as required. 

Y N 

6. Establish a collaborative disclosure 

process to ensure that patients are 

appropriately informed. 

A local policy was established and is in 

congruence with VHA policy. 

Y N 

7. Educate managers and staff on the 

adverse event disclosure requirements and 

responsibilities outlined in VHA and facility 

policy. 

For FY 2009, a power point was 

presented to medical staff. In FY 2010, 

formal training was conducted. Future 

medical staff orientation will include 

disclosure training. 

Y N 

8. Ensure the quality manager, the risk 

manager, and other key staff members 

establish a process to review and monitor 

the adverse event disclosure process so that 

improvements can be made. 

In addition to risk management 

screening, disclosures are considered 

during PRs and patient incident report 

reviews. Daily communication and 

monthly QLC meetings ensure all 

potential cases are considered. Risk 

management is actively involved and 

monitors progress of follow-up actions. 

Y N 

9. Complete RCAs in accordance with VHA 

policy. 

All RCAs have been completed within 

the required timeframes. 

Y N 

10. Track and trend data on medication 

reconciliation to identify opportunities for 

improvement, and present results to the 

HLC for action. 

Medication reconciliation data is 

tracked and trended to identify 

opportunities for improvement. Results 

are submitted monthly to the Patient 

Safety Committee and the Inpatient 

and Outpatient System Redesign 

Subcommittees for action. 

Y N 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

11. Track and trend UM data to identify 

opportunities for improvement, and present 

UM data to the HLC for action. 

UM data is tracked and trended to 

identify improvement opportunities. 

Data is presented monthly to the UM 

Committee and quarterly to the QLC. 

Y N 

12. Assign a physician advisor to the UM 

program, and ensure proper training. 

All physician advisors have been 

identified and trained for each area, 

including medicine, the ED, and 

surgery. 

Y N 

13. Conduct inter-rater reliability reviews in 

accordance with VHA policy. 

All UM reviewers complete inter-rater 

reliability reviews, and all have passed 

with 80 percent or better. 

Y N 

14. Track and trend moderate sedation data 

to identify opportunities for improvement, 

and present trended data to the HLC for 

action. 

Moderate sedation tracking and 

trending is a standing quarterly report 

for the QLC. It is reviewed monthly at 

the Invasive Procedures Committee. 

Y N 

15. Track and trend code data to identify 

opportunities for improvement, and present 

code data to the HLC for action. 

Code information is a standing item for 

the QLC and is reviewed quarterly. It 

is reviewed monthly by the 

Cardiopulmonary Resuscitation 

Committee. 

Y N 

CPRS Business Rules 

16. Ensure CPRS business rules comply 

with VHA policy and Office of Information 

guidance related to altering signed medical 

record notes. 

Medical record monitors are reviewed 

monthly at the Health Information 

Management Committee and quarterly 

at the QLC. Monitor includes review 

and report related to altering medical 

record notes. 

Y N 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

Survey of Healthcare Experiences of 

Patients 

17. Develop an action plan to improve 

patient satisfaction and overall scores, and 

identify specific staff responsibilities. 

Committees have been realigned to 

include a Customer Service Steering 

Committee and three subcommittees. 

Action plans are updated monthly. 

Champions and facilitators are 

identified for each action plan. 

Y N 

EOC 

18. Include nurse managers in EOC rounds 

in their respective areas. 

Nurse managers are required to and 

actively participate in regularly 

scheduled EOC rounds. 

Y N 

19. Address identified housekeeping issues. Additional housekeepers have been 

hired, and housekeeping services are 

available daily for each shift. An 

inspection sheet for public areas is 

completed by the housekeeper and 

reviewed by the supervisor to ensure 

proper cleaning. 

Y N 

CBOCs 

20. Require the contracting office to ensure 

that appropriate position risk and sensitivity 

designations are made. 

The contracting officer receives 

completed VA Form 2280 (used to 

designate the appropriate position risk 

and sensitivity) prior to initiating a 

background check. 

Y N 

21. Require the contracting officer to ensure 

appropriate levels of background screening 

are monitored and tracked to completion. 

The contracting officer maintains an 

electronic list of all initiated background 

checks and monitors until completed. 

Y N 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

Breast Cancer Management 

22. Ensure providers document patient 

notification of abnormal mammogram results 

in the medical record. 

Radiology staff monitor mammography 

appointments and results daily. 

Providers are notified of all abnormal 

mammogram results and contact the 

patient. Documentation is entered into 

the medical record. Radiology staff 

make and track follow-up 

appointments. 

Y N 

23. Require mammography services to be 

completed by the contract provider within 

30 days. 

Mammography appointments are 

completed within 30 days by the 

contract provider. The average 

timeframe for communicating test 

results to the facility is 4 days. 

Y N 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the John D. Dingell VA Medical Center, Detroit MI 

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 

quarters 1–3 of FY 2010. 

Table 1 

FY 2010 

(inpatient target = 64, outpatient target = 56) 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 2 

Inpatient 

Score 

Quarter 3 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Outpatient 

Score 

Quarter 3 

Facility 53.9 57.1 52.2 47.3 44.6 51.1 

VISN 67.4 66.1 65.6 53.4 54.5 56.3 

VHA 63.3 63.9 64.5 54.7 55.2 54.8 

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 15 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

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

conditions11 received hospital care. The mortality (or death) rates focus on whether 

patients died within 30 days of their hospitalization. The rates of readmission focus on 

whether patients were hospitalized again within 30 days. Mortality rates and rates of 

readmission show whether a hospital is doing its best to prevent complications, teach 

patients at discharge, and ensure patients make a smooth transition to their home or 

another setting. The hospital mortality rates and rates of readmission are based on 

people who are 65 and older. These comparisons are “adjusted” to take into account 

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

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

FYs 2006–2009. 

Table 2 

Mortality Readmission 

Heart Attack CHF Pneumonia Heart Attack CHF Pneumonia 

Facility 13.22 9.42 16.24 19.98 22 15.42 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

11 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 sedition of 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 16 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: December 30, 2010 

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

Subject: CAP Review of the John D. Dingell VA Medical Center, 

Detroit, MI 

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

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

Per your request, attached is the response to the draft report from Detroit 

VAMC. If you have any questions, please contact Jim Rice, VISN 11 

QMO, at (734) 222-4314. 

MICHAEL S. FINEGAN
 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 December 27, 2010 

From:	 Director, John D. Dingell VA Medical Center (553/00) 

Subject:	 CAP Review of the John D. Dingell VA Medical Center, 

Detroit, MI 

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

1. I would like to take this opportunity to express my gratitude for the 

helpful insight provided by this OIG team during the CAP review. The 

opportunities for improvement have been embraced by all of us and will 

serve as the way forward for continuous improvement as we strive to meet 

the needs of our Veterans. 

2. We have reviewed each recommendation and developed a plan of 

action that will meet the intent of the associated recommendation. Each 

plan will be implemented expeditiously and thoroughly monitored to 

satisfactory completion. 

3. Thank you again for your assistance during this visit. 

//es// on file 

Pamela Reeves, M.D. 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Comments to Office of Inspector General’s Report
 

The following Director’s comments are submitted in response to the recommendations 

in the Office of Inspector General report: 

OIG Recommendations 

Recommendation 1. We recommended that processes be strengthened to ensure that 

medication security is maintained. 

Concur 

Target date for completion: March 31, 2011 

1.	 Self closing door hinges and electronic keyless locks will be installed on all 

medication room doors. (3/31/2011) 

2.	 Immediately following the OIG recommendations, staff was educated to close and 

lock the medication room door as they are exiting the medication room. Beginning 

1/3 through 3/31/2011, all nursing staff will be in-serviced regarding medication 

safety and security. Staff will be counseled if they are seen leaving the medication 

room unsecured. 

3.	 Beginning the week of 12/27/10, in the acute care areas, the charge nurses will 

perform daily spot checks to monitor the safety and security of medication rooms. 

The Clinical Nurse Managers will conduct weekly monitors to check for unsecured 

medications within outpatient examination rooms and acute care areas. The CNM 

rounding checklist will be revised to include areas for medication security. 

4.	 Nursing monitors will be reported monthly to nursing leadership and the Patient 

Safety Committee. Reporting will include aggregated and trended data. The first 

report to Patient Safety Committee is scheduled for February 2011. 

Recommendation 2. We recommended that sharp items and cleaning supplies be 

secured at all times. 

Concur 

Target date for completion: March 31, 2011 

1.	 By 2/1/2011, in-service education will be provided to all nursing and EMS staff 

regarding the proper storage and disposal of sharps items and cleaning supplies. 

2.	 Effective immediately, clinical nurse managers will begin weekly unit 

checks/monitors for sharps and cleaning supplies. The CNM rounding checklist will 

be revised to include areas for proper storage and disposal of sharps items and 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

cleaning supplies. Monitors will be reported on a regular basis to nursing leadership 

and the Patient Safety Committee beginning February 2011. 

3.	 Effective immediately, System Redesign team will begin review of the facility wide 

process for storage and disposal of sharps and cleaning supplies to determine a 

standardized process or 5S approach for each practice. (Target date for completion 

3/31/2011) 

Recommendation 3. We recommended that processes be strengthened to ensure 

quick responses to the emergency call system on the locked behavioral health unit. 

Concur 

Target date for completion: February 28, 2011 

1.	 By January 10, 2011, in-service education will be provided to all behavioral health 

unit patient care staff regarding the protocols and expectations for responding to 

emergency call lights. 

2.	 By January 15, 2011, the Clinical Nurse Managers for each unit will initiate weekly 

monitors for all inpatient units, to test that a timely response to emergency call lights 

is occurring. The CNM rounding checklist will be revised to include the emergency 

call light test. 

3.	 This information will be reported on a monthly basis to nursing leadership and the 

Patient Safety Committee beginning February 2011 meeting. 

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

confidential patient information is secured. 

Concur 

Target date for completion: January 31, 2011 

1.	 By January 31, 2011, all areas identified in the OIG recommendations will complete 

an in-service training regarding information security. In addition, each employee in 

these areas will be required to retake the Information Security and Privacy 

awareness training prior to January 31, 2011. 

2.	 By January 31, 2011, electronic keyless locks will be installed on the printer room 

doors in the emergency department and in the Firm D area to prevent patient 

access. The EoC rounding checklist will be revised to include on-going assessment 

of information security needs. 

3.	 By January 31, 2011, all computer screens in areas with patient access will be 

checked to ensure privacy screens are in place and “Do Not Remove” warning 

labels will be placed on the privacy screens. In addition, The EoC rounding checklist 

VA OIG Office of Healthcare Inspections 20 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

will be revised to include inspection for privacy screen monitors. Information from 

the EoC rounds is reported to the EoC Committee on a monthly basis. 

Recommendation 5. We recommended that annual bloodborne pathogens training 

and N95 respirator fit testing be completed and documented. 

Concur 

Target date for completion: January 31, 2011 

Respiratory Protection Fit Testing Action Plan 

In October 2010, fit testing was conducted for the core groups, additional fit testers were 

trained, and core T&Ls were added to LMS as requiring respirator fit testing with VA 

course VA 2323. This will allow for better tracking and provide automated yearly 

reminders to employees. Additional fit testing kits were purchased. 

1.	 By 1/15/2011, the Safety Office will have updated the respirator policy to reflect the 

current program. 

2.	 The Safety office will continue to track fit testing compliance in LMS and report 

quarterly progress to the EoC Committee (standing agenda item). 

3.	 Maintaining compliance with LMS requirements is a performance measure for all 

service chiefs and employees. 

Bloodborne Pathogens Training 

1.	 This training is currently tracked using LMS; Infection Control will now maintain 

oversight for compliance and will report quarterly to the Infection Control 

Committee – Completed. 

Recommendation 6. We recommended that privileges appropriately indicate the 

setting where they may be practiced. 

Concur 

Target date for completion: January 31, 2011 

On all privilege forms, option 13 under Medical Center Settings, “all of the above” has 

been eliminated. Each Service Chief will now be required to specify exactly where each 

provider will be allowed to practice each privilege. Effective immediately, all new 

applicants and re-privilege requests will use the newly approved “Delineation of 

Privileges” form for their respective Service. 

VA OIG Office of Healthcare Inspections 21 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Recommendation 7. We recommended that PR actions and follow-up be documented 

in PRC meeting minutes. 

Concur 

Target date for completion: November 19, 2010 

At the time of review, a column was added on the Peer Review tracking log sheet to 

indicate the date that the issue was officially closed. The tracking log is reviewed for 

open issues at each Clinical Care Committee (Medical Executive Committee). 

Recommendation 8. We recommended that moderate sedation documentation 

includes all required components. 

Concur 

Target date for completion: March 31, 2011 

1.	 By 1/31/2011, create a standardized process for all moderate sedation 

areas/procedures. The Endoscopy Moderate Sedation Pre-procedure Assessment 

note will be changed to a generic title; i.e. remove “ENDOSCOPY” in the title, and all 

fields within template will be changed to mandatory. The fields may be answered by 

a negative response if indicated. The use of the paper “tri-fold” in the Radiology 

area will be eliminated and CPRS will be utilized for all moderate sedation procedure 

notes throughout the facility. Training for the new template will be completed by 

each provider prior to implementation on 1/31/2011. 

2.	 An on-going monitor will begin 2/1/2011 to confirm and maintain hospital-wide 

compliance. The monitor will be based on Joint Commission standards and sample 

size requirements. The Moderate Sedation Committee will be responsible for 

aggregating and analyzing the information and reporting on a regular basis to the 

Clinical Care Committee as well as the Quality Management Leadership Committee. 

The first report is scheduled for 3/2011. 

Recommendation 9. We recommended that normal test results be consistently 

communicated to patients within the specified timeframe. 

Concur 

Target date for completion: January 31, 2011 

1.	 In November 2010, the “Tests Notification” policy was completed and the “Tests 

Notification” letter template was approved by the Medical/Dental staff and the ISO 

and privacy officers. 

VA OIG Office of Healthcare Inspections 22 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

2.	 In December 2010, a standard operating procedure (SOP) was established for all 

areas. This SOP will be implemented in all areas by 1/31/2011. The SOP summary 

is listed below. 

i.	 Provider enters a test notification note in CPRS and prints the letter. 

ii.	 Notification letters will be automatically printed and ward administration 

staff will mail the letters. 

iii.	 Training of the providers on the utilization of tests notification template 

will be completed by 1/31/2011. 

3.	 The medical record review will include a monitor of compliance for patient 

notification of normal test results. The monitor/analysis will be reviewed monthly at 

the Medical Records Committee and quarterly at the Clinical Care Committee. 

Recommendation 10. We recommended that personnel adhere to American Society 

of Health-System Pharmacists guidelines for preparation and administration of 

hazardous drugs. 

Concur 

Target date for completion: January 15, 2011 

1.	 Nursing staff responsible for the administration of chemotherapeutic agents have 

been educated on the proper use of the absorbent pad during administration (week 

of 12/27/2010). 

2.	 A standard operating procedure/check list will be created and posted in the work 

areas to include the use of the absorbent pad (1/15/2011). 

3.	 Beginning 1/3/2011, the Clinical Nurse Manager will conduct weekly spot checks to 

monitor the use of the absorbent pad. This information will be reported to nursing 

leadership and the Patient Safety Committee. 

Recommendation 11. We recommended that hazardous waste containers be provided 

that are large enough to accommodate all PPE without pushing or forcing. 

Concur 

Target date for completion: January 15, 2011 

1.	 During the site visit, pharmacy service obtained a separate hazardous waste 

container to be used only for worn gowns and gloves. There are currently two large 

containers, one for sharps items and one for hazardous waste. 

VA OIG Office of Healthcare Inspections 23 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

2.	 To ensure on-going and facility wide compliance, review of adequate and 

appropriate hazardous waste containers will be added to the EoC Rounding 

checklist as well as the daily EMS checklist (1/15/2011). 

3.	 Staff will be in-serviced on the proper methods for disposal of sharps and hazardous 

waste materials as well as when it is appropriate to request removal or replacement 

of disposal containers. 

Recommendation 12. 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: January 31, 2011 

1.	 All educational materials and CPRS documentation templates are currently in place. 

Clinical Nurse Managers will begin monitoring nursing compliance with this 

requirement on 1/3/2011. 

2.	 Monitor outcomes/analysis will be reported monthly to the Infection Control 

Committee and quarterly to the Clinical Care Committee beginning January 2011. 

Recommendation 13. We recommended that employees receive annual MDRO 

education and that the training is consistently documented. 

Concur 

Target date for completion: March 15, 2011 

1.	 Education Service to assign “MDRO-Infection Control Principles in Health Care” in 

LMS to designated staff – target date 1/15/2010. 

2.	 Education Service and Infection Control to develop MDRO LMS module for EMS 

staff – target date 2/15/2011. 

3.	 Beginning 1/15/2011, Infection Control Service will run LMS compliance reports and 

will notify all Service Chiefs/Managers of required follow-up. In addition, monthly 

automated emails are generated by LMS for required training. These automated 

e-mails are sent to the employee and his/her supervisor. Maintaining LMS 

compliance is included in all service chiefs and employee performance evaluations. 

4.	 To ensure on-going facility wide compliance, MDRO training compliance will be 

reviewed quarterly (standing agenda item) via the EoC Committee. 

VA OIG Office of Healthcare Inspections 24 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Recommendation 14. We recommended that managers ensure that advance directive 

notification and screening are conducted in accordance with VHA policy. 

Concur 

Target date for completion: February 28, 2011 

1.	 The local policy will be revised to include all requirements by 1/31/2011. 

2.	 The admission process will be revised to ensure the advance directive information is 

included in the admission packet for all types of admissions (including direct admits), 

and that the information is reviewed during the nursing admission process 

(2/15/2011). 

3.	 In order to account for inpatient admissions, informatics has added a required field in 

the advance directives section on the nursing admission data base. The nurse 

cannot exit the admission data base until the required field/screen is complete (see 

below). A positive screen will result in a social work referral for advance directives. 

a.	 Did the patient want more information about advance directives? Y or N 

b.	 Is assistance needed to complete the advance directives? Y or N 

4.	 For the outpatient area, a one-time clinical reminder will be developed to address 

advance directives. A positive screen will result in a social work referral for advance 

directives (1/31/2011). 

5.	 Monthly medical records review will include review of compliance with advance 

directive documentation requirements (2/1/2011). Analysis and reporting of the 

monitor will occur monthly at the Medical Records Committee and quarterly at the 

Clinical Care Committee (3/2011). 

Recommendation 15. We recommended that processes be strengthened to ensure 

that discharge instructions include education for diet restrictions. 

Concur 

Target date for completion: January 31, 2011 

1.	 The nursing discharge summary note will be revised to include a required field for 

diet instructions. The nurse cannot exit the note until this section is addressed. If 

the screen is positive for a specially ordered diet, the specific diet instructions will be 

automatically printed and included in the nursing discharge instructions. 

VA OIG Office of Healthcare Inspections 25 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact Wachita Haywood, BSN, RN, Associate Director 

Chicago Office of Healthcare Inspections 

Contributors Roberta Thompson, MSW, Team Leader 

Lisa Barnes, MSW 

Jody Marquez, BSN, RN 

Jennifer Reed, RN-BC 

Ann Ver Linden, BSN, RN 

Judy Brown, Program Support Assistant 

Report Produced under the direction of Verena Briley-Hudson, MN, RN 

Preparation Director, Chicago Office of Healthcare Inspections 

VA OIG Office of Healthcare Inspections 26 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans in Partnership Network (10N11) 

Director, John D. Dingell VA Medical Center (553/00) 

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: Carl Levin, Debbie Stabenow 

U.S. House of Representatives: Dan Benishek; Hansen Clarke; John Conyers, Jr.; 

John D. Dingell; Bill Huizenga; Sander Levin; Thaddeus McCotter; Candice Miller; 

Gary Peters 

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

VA OIG Office of Healthcare Inspections 27