Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 10-03093-82 

Combined Assessment Program
 

Review of the
 

VA Salt Lake City Health Care System
 

Salt Lake City, Utah
 

February 7, 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 Salt Lake City Health Care System, Salt Lake City, UT 

Glossary 

ACLS Advanced Cardiac Life Support 

AES All Employee Survey 

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 

CPR cardiopulmonary resuscitation 

EOC environment of care 

facility VA Salt Lake City Health Care System 

FTE full-time employee equivalents 

FY fiscal year 

MDRO multidrug-resistant organisms 

OEF Operation Enduring Freedom 

OI Office of Information 

OIF Operation Iraqi Freedom 

OIG Office of Inspector General 

PRRTP Psychosocial Residential Rehabilitation Treatment 

Program 

PSB Professional Standards Board 

QM quality management 

RCA root cause analysis 

SOPs standard operating procedures 

VBA Veterans Benefits Administration 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Salt Lake City Health Care System, Salt Lake City, UT 

Table of Contents 

Page 

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

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

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

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

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

Results ........................................................................................................................ 3
 

Review Activities With Recommendations .............................................................. 3
 

Physician C&P................................................................................................... 3
 

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

Management of Test Results............................................................................. 4
 

Review Activities Without Recommendations ......................................................... 5
 

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

EOC................................................................................................................... 5
 

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

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

Comments................................................................................................................... 6
 

Appendixes 

A. Facility Profile .................................................................................................... 7
 

B. Follow-Up on Previous Recommendations........................................................ 8
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 9
 

D. VISN Director Comments .................................................................................. 11
 

E. Facility Director Comments ............................................................................... 12
 

F. OIG Contact and Staff Acknowledgments ......................................................... 15
 

G. Report Distribution ............................................................................................ 16
 

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

Review of the VA Salt Lake City Health Care System, 

Salt Lake City, UT 

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 

December 6, 2010. 

Review Results: The review covered 

seven activities. We made no 

recommendations in the following 

activities: 

	 Coordination of Care 

	 Environment of Care 

	 Management of Multidrug-Resistant 

Organisms 

	 Medication Management 

The facility’s reported accomplishments 

were its extensive and innovative 

outreach efforts through the Veterans 

Outreach Program and a widespread 

culture of safety through staff 

involvement throughout the 

organization. 

Recommendations: We made 

recommendations in the following three 

activities: 

Physician Credentialing and Privileging: 

Require that two efforts to obtain 

verification of clinical privileges held at 

other institutions be made and 

documented in the credentialing and 

privileging folders. Ensure that 

Professional Standards Board meeting 

minutes reflect sufficient discussion of 

competency data. 

Quality Management: Require that 

processes to ensure complete 

documentation of moderate sedation be 

fully implemented and monitored for 

compliance. 

Management of Test Results: Require 

that normal test results be consistently 

communicated to patients within the 

specified timeframe. 

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 VA Salt Lake City Health Care System, Salt Lake City, UT 

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 December 9, 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 VA Salt Lake City Health Care System, Salt 

Lake City, Utah, Report No. 08-00819-143, June 10, 2008). 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the VA Salt Lake City Health Care System, Salt Lake City, UT 

The facility had corrected all findings from that review. (See 

Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings for 350 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 

The facility conducts extensive outreach programs for all 

veterans, including those not currently enrolled. The 

OEF/OIF outreach program achieves 100 percent 

participation in Post-Deployment Health Reassessments. 

The facility uses various social media, such as Facebook, 

Twitter, and e-mail, for continuous communication with 

veterans and the community. The facility’s website is 

user-friendly, informational, and interactive. The Annual 

Veterans Day Info-thon is an innovative approach to raise 

awareness amongst veterans. It is a collaborative effort 

between VHA, VBA, and the Utah Department of Veterans 

Affairs to answer questions about access to care and 

benefits and to provide guidance related to personal needs. 

A local television station broadcasts the program, which 

results in thousands of calls for information. 

Additionally, the facility’s Justice Outreach Program assigns 

a social worker to the judicial systems (jails and courts) 

and facilitates alternative treatments rather than 

incarceration for first offense veterans. Two federal 

judges—one a veteran—recognize the varied challenges 

veterans face and work to integrate them into VHA care and 

therapy rather than sentencing them to an already 

overcrowded state facility. 

The facility developed a widespread culture of safety through 

staff involvement throughout the organization. During 

FY 2010, more than 135 physicians, nurses, pharmacy staff, 

ancillary clinical staff, business office staff, and clerks 

participated in RCA teams to identify and resolve patient 

safety issues. One hour each week, leadership meets to 

hear RCA team closeouts or to address other patient safety 

Veterans Outreach 

Program 

Culture of Patient 

Safety 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the VA Salt Lake City Health Care System, Salt Lake City, UT 

concerns. Leadership maintains an open-door policy for 

employees wishing to report or discuss patient safety 

concerns. In addition, patient safety information is presented 

to all new employees to emphasize that patient safety is an 

integral part of the mission at the facility. AES scores reflect 

that employees feel that a culture of safety exists. 

The patient safety program has been recognized by the 

National Center for Patient Safety for 3 consecutive years. 

The facility was awarded the Bronze Cornerstone Award in 

2008, the Silver Cornerstone Award in 2009, and the Gold 

Cornerstone Award in 2010. 

Results 

Review Activities With Recommendations 

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 17 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. 

Privileging. VHA requires that a minimum of two efforts to 

obtain verification of clinical privileges held at other 

institutions are to be made and documented in C&P folders.1 

We identified that only one effort was documented in each of 

the 17 C&P files reviewed. 

VHA also requires that the medical staff’s Executive 

Committee or PSB meeting minutes reflect the documents 

reviewed and the rationale for the decision made for initial 

privileging and final reprivileging action. PSB meeting 

minutes did not reflect the documents reviewed or the 

rationale for initial privileges or reprivileging in 

11 (65 percent) of the 17 files reviewed. 

Recommendations	 1. We recommended that two efforts to obtain verification 

of clinical privileges held at other institutions be made and 

documented in C&P folders. 

2. We recommended that PSB meeting minutes reflect 

sufficient discussion of competency data. 

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

VA OIG Office of Healthcare Inspections 3 
CAP Review of the VA Salt Lake City Health Care System, Salt Lake City, UT 

QM	 The purpose of this review was to evaluate whether the 

facility had a comprehensive QM program in accordance with 

applicable requirements and whether senior managers 

actively supported the program’s activities. 

We interviewed senior managers and QM personnel, and we 

evaluated policies, meeting minutes, and other relevant 

documents. We identified the following area that needed 

improvement. 

Moderate Sedation. VHA requires that staff assess and 

monitor patients undergoing moderate sedation.2 We 

reviewed the medical records of 15 patients who had 

moderate sedation and found that 12 (80 percent) of the 

records did not include documentation of airway assessment. 

This was identified by the facility prior to our onsite review, 

and new processes and training have been implemented. In 

addition, two (13 percent) records did not include 

documentation of organ systems, re-evaluation immediately 

prior to the procedure, and assessment of risk. 

Recommendation	 3. We recommended that processes to ensure complete 

documentation of moderate sedation be fully implemented 

and monitored for compliance. 

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.3 

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.4 We reviewed the medical 

records of 20 patients who had normal test results and found 

that 13 (65 percent) of the 20 records contained documented 

evidence that the facility had communicated the results to the 

patients. 

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

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

VA OIG Office of Healthcare Inspections 4 
CAP Review of the VA Salt Lake City Health Care System, Salt Lake City, UT 

Recommendation	 4. We recommended that normal test results be 

consistently communicated to patients within the specified 

timeframe. 

Review Activities Without Recommendations 

COC 

EOC 

Management of 

MDRO 

Medication 

Management 

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 and determined that 

the facility generally met requirements in these areas. We 

made no recommendations. 

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 medical/surgical, intensive care, and 

locked mental health inpatient units; the eye and dental 

outpatient clinics; and the urgent care clinic. The facility 

maintained a generally clean and safe environment. We 

made no recommendations. 

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 reviewed the facility’s infection control risk assessment, 

employee training records, and medical records. We 

inspected the medical/surgical and intensive care units and 

interviewed employees. We determined that the facility 

had an effective program in place. We made no 

recommendations. 

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. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the VA Salt Lake City Health Care System, Salt Lake City, UT 

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 11–14, for the full text of the Directors’ comments.) We will follow up on 

the planned actions until they are completed. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the VA Salt Lake City Health Care System, Salt Lake City, UT 

Appendix A 

Facility Profile5 

Type of Organization Tertiary care medical center 

Complexity Level 1b 

VISN 19 

CBOCs West Valley City, UT 

Orem, UT 

St. George, UT 

Ogden, UT 

Pocatello, ID 

Fountain Green, UT 

Nephi, UT 

Roosevelt, UT 

Elko, NV 

Ely, NV 

Veteran Population in Catchment Area 182,000 

Type and Number of Total Operating Beds: 

 Hospital, including PRRTP 121 

 CLC/Nursing Home Care Unit NA 

 Other NA 

Medical School Affiliation(s) University of Utah Medical Center 

University of Utah College of Nursing 

Utah State University 

Weber State University 

Salt Lake Community College 

Brigham Young University 

 Number of Residents 260 

FY 2010 Prior FY (2009) 

Resources (in millions): 

 Total Medical Care Budget $360.1 $324.2 

 Medical Care Expenditures $359.3 $321.8 

Total Medical Care FTE 1,662.5 1,534.5 

Workload: 

 Number of Station Level Unique 

Patients 

45,704 45,629 

 Inpatient Days of Care: 

o Acute Care 31,795 30,109 

o CLC/Nursing Home Care Unit NA NA 

Hospital Discharges 5,747 5,674 

Total Average Daily Census (including all bed 

types) 

100 96 

Cumulative Occupancy Rate 82.66% 79.01% 

Outpatient Visits 552,403 496,287 

5 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the VA Salt Lake City Health Care System, Salt Lake City, UT 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Ensure that processing times for RCAs 

are improved. 

During FY 2010, the Patient Safety 

Program completed 100 percent of 

RCAs within 45 days. 

Y N 

2. Ensure that all clinically active staff have 

current CPR and ACLS training, as required 

by VHA and local policy. 

A tracking system is in place to assure 

compliance. 

Y N 

Business Rules for Veterans Health 

Information Systems 

3. Require that Computerized Patient 

Record System business rules are in 

compliance with VHA policy and OI 

guidance. 

All current business rules are in 

compliance with VHA policy and OI 

guidance. 

Y N 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the VA Salt Lake City Health Care System, Salt Lake City, UT 

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 67.5 61.7 66.4 57.2 48.6 54.8 

VISN 65.9 62.5 64.0 53.9 52.8 52.6 

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. 

0.0 

0.5 

1.0 

1.5 

2.0 

2.5 

3.0 

3.5 

4.0 

4.5 

5.0 

2008 2009 2010 

Facility 

VISN 

National 

VA ALL EMPLOYEE SURVEY 

OVERALL SATISFACTION Figure 1: 

LEVEL OF SATISFACTION 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the VA Salt Lake City Health Care System, Salt Lake City, UT 

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

conditions6 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 13.55 8.31 14.2 19.94 21.94 13.91 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

6 CHF is a weakening of the heart’s pumping power. With heart failure, the 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 may become damaged from lack of oxygen. Pneumonia is a serious 

lung infection that fills the lungs with mucus and may cause difficulty in breathing, fever, cough, and fatigue. 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the VA Salt Lake City Health Care System, Salt Lake City, UT 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: January 25, 2011 

From: Director, Rocky Mountain Network (10N19) 

Subject: CAP Review of the VA Salt Lake City Health Care 

System, Salt Lake City, UT 

To: Director, Denver Office of Healthcare Inspections (54DV) 

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

I have reviewed the response to the draft OIG CAP report provided by the 

George E. Wahlen VA Salt Lake City Health Care System and concur with 

the response. I am submitting it to your office as requested. If you have 

any questions or require additional information, please contact 

Aggie Worth, VISN QMO at (303) 639-6984. 

VISN 19 Network Director 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the VA Salt Lake City Health Care System, Salt Lake City, UT 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 January 18, 2011 

From:	 Director, VA Salt Lake City Health Care System (660/00) 

Subject:	 CAP Review of the VA Salt Lake City Health Care 

System, Salt Lake City, UT 

To:	 Director, Rocky Mountain Network (10N19) 

1.	 I would like to express my sincere appreciation to the OIG Combined 

Assessment Program review team for their professionalism and 

consultative feedback to our staff during the review, which was 

conducted December 6–9, 2010. We appreciate their thorough review 

and the opportunity to further improve the quality care we provide 

Veterans every day. 

2.	 I have reviewed the recommendations and concur with the findings. 

Our comments and planned actions are outlined below. 

3.	 If you have questions or require additional information, please do not 

hesitate to contact Nena Saunders, Chief, Quality Management, at 

(801) 582-1565, ext. 4608. 

Director 

George E. Wahlen VA Salt Lake City Health Care System 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the VA Salt Lake City Health Care System, Salt Lake City, UT 

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 two efforts to obtain verification of clinical 

privileges held at other institutions be made and documented in C&P folders. 

Concur 

Target date for completion: Completed December 8, 2010 

The process has been changed and the process checklist in the Credentialing and 

Privileging office has been modified to include two efforts to obtain verification of clinical 

privileges held at other institutions and documented in the Credentialing and Privileging 

folder. 

Recommendation 2. We recommended that PSB meeting minutes reflect sufficient 

discussion of competency data. 

Concur 

Target date for completion: Completed December 8, 2010 

Expectations have been clarified with Professional Standards Board members to 

enhance discussion during board meetings. The Quality Manager is now participating 

as a non-voting member to encourage discussion, clarify PSB member comments, and 

insure robust capture of discussion in the minutes. Board discussions are being 

recorded to assist the committee secretary in fully capturing the discussion. 

Recommendation 3. We recommended that processes to ensure complete 

documentation of moderate sedation be fully implemented and monitored for 

compliance. 

Concur 

Target date for completion: Ongoing monitoring completion target date: April 15, 2011 

This organization was aware of the deficiency and had taken measures to correct, 

through the implementation of a new policy, documentation template and provider 

education. The template will guide the provider to complete and document a full 

assessment. Full documentation will include an airway assessment and organ system 

assessment immediately prior to the induction of moderate sedation. The Quality 

Management office will conduct an audit of 60 medical records per month during the 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the VA Salt Lake City Health Care System, Salt Lake City, UT 

months of January, February, and March to validate 90 percent compliance with VHA 

Directive and local policy. 

Recommendation 4. We recommended that normal test results be consistently 

communicated to patients within the specified timeframe. 

Concur 

Target date for completion: Ongoing monitoring completion target date: May 1, 2011 

The policy has been revised clarifying provider expectations, which require that normal 

test results be consistently communicated to patients within 14 days. The Chief of Staff 

has conducted staff education and reinforced the policy in the Clinical Executive 

Committee. The Chief of Staff will also reinforce education in all Provider-Service Chief 

meetings and through electronic messages. The Medical Records Committee will 

conduct an audit of 200 medical records per month during the months of February, 

March and April 2011 to validate 90 percent compliance with VHA Directive and local 

policy. 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the VA Salt Lake City Health Care System, Salt Lake City, UT 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact Virginia L. Solana, Director, Team Leader 

Denver Office of Healthcare Inspections 

Contributors Stephanie B. Hensel 

Clarissa B. Reynolds 

Ann Ver Linden 

Cheryl A. Walker 

Laura L. Dulcie 

Michael Morse, Office of Investigations 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the VA Salt Lake City Health Care System, Salt Lake City, UT 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Rocky Mountain Network (10N19) 

Director, VA Salt Lake City Health Care System (660/00) 

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: Orrin G. Hatch, Mike Lee 

U.S. House of Representatives: Jim Matheson 

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

VA OIG Office of Healthcare Inspections 16