Department of Veterans Affairs

Office of Inspector General 

Office of Healthcare Inspections 

Report No. 14-02066-266 

Combined Assessment Program 

Review of the 

Providence VA Medical Center 

Providence, Rhode Island 

September 2, 2014 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov 

(Hotline Information: www.va.gov/oig/hotline) 
CAP Review of the Providence VA Medical Center, Providence, RI 

Glossary 

CAP Combined Assessment Program 

EHR electronic health record 

EOC environment of care 

facility Providence VA Medical Center 

FY fiscal year 

MEC Medical Executive Committee 

MRI magnetic resonance imaging 

NA not applicable 

NM not met 

OIG Office of Inspector General 

PACU post-anesthesia care unit 

PRC Peer Review Committee 

PT/INR prothrombin time and international normalized ratio 

PTT partial thromboplastin time 

QM quality management 

SDS same day surgery 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Providence VA Medical Center, Providence, RI 

Table of Contents 

Page 

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

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

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

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

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

Results and Recommendations................................................................................ 4
 

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

EOC ........................................................................................................................ 7
 

Medication Management......................................................................................... 10
 

Coordination of Care ............................................................................................... 11
 

Acute Ischemic Stroke Care ................................................................................... 12
 

MRI Safety .............................................................................................................. 14
 

Appendixes 

A. Facility Profile .................................................................................................... 15
 

B. Strategic Analytics for Improvement and Learning ............................................ 16
 

C. VISN Director Comments .................................................................................. 19
 

D. Facility Director Comments ............................................................................... 20
 

E. OIG Contact and Staff Acknowledgments ......................................................... 26
 

F. Report Distribution ............................................................................................. 27
 

G. Endnotes ........................................................................................................... 28
 

VA OIG Office of Healthcare Inspections 
 

 

 

CAP Review of the Providence VA Medical Center, Providence, RI 

Executive Summary 

Review Purpose: The purpose of the review was to evaluate selected health care 

facility operations, focusing on patient care quality and the environment of care, and to 

provide crime awareness briefings. We conducted the review the week of 

June 16, 2014. 

Review Results: The review covered six activities. We made no recommendations 

in the following three activities: 

 Medication Management 

 Coordination of Care 

 Magnetic Resonance Imaging Safety 

The facility’s reported accomplishments were Compensation and Pension Systems 

redesign, accreditation by the Commission on Cancer, and Pathway to Excellence® 

designation by the American Nurses Credentialing Center. 

Recommendations: We made recommendations in the following three activities: 

Quality Management: Report completed actions from peer reviews to the Peer Review 

Committee. Ensure the Special Care Committee collects data that measures 

performance in responding to codes. Require the Surgical Service Staff Committee to 

meet monthly and the Blood Usage Review Committee to meet at least quarterly. 

Include the results of proficiency testing and the results of peer reviews when 

transfusions did not meet criteria in the blood/transfusions usage review process. 

Ensure that when data analysis indicates problems or opportunities for improvement, 

actions are consistently identified, implemented, and followed to resolution in surgical 

performance improvement activities, electronic health record quality reviews, and 

blood/transfusion reviews. 

Environment of Care: Ensure all patient care areas and public rest rooms are clean. 

Follow procedures for terminal cleaning of patient rooms. Ensure that in patient care 

areas, damaged furniture is repaired or removed from service and damaged surfaces 

are repaired. Bring the pharmacy clean room for compounding sterile products into 

compliance with United States Pharmacopeia <797> cleanliness, sterility, and 

monitoring standards. Ensure all required members of the Environment of Care 

Committee consistently attend committee meetings, and strengthen the program to 

ensure effective surveillance activities. Require VA Police to update the Security 

Management Plan annually and to submit quarterly security reports to the Environment 

of Care Committee. 

Acute Ischemic Stroke Care: Complete and document National Institutes of Health 

stroke scales for each stroke patient, and screen patients for difficulty swallowing prior 

VA OIG Office of Healthcare Inspections i 
CAP Review of the Providence VA Medical Center, Providence, RI 

to oral intake. Provide printed stroke education to patients upon discharge. Ensure 

assessment of patients presenting with stroke symptoms includes facility required blood 

tests. 

Comments 

The Veterans Integrated Service Network and Facility Directors agreed with the 

Combined Assessment Program review findings and recommendations and provided 

acceptable improvement plans. (See Appendixes C and D, pages 19–25, for the full 

text of the Directors’ comments.) 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 ii 
CAP Review of the Providence VA Medical Center, Providence, RI 

Objectives and Scope 

Objectives 

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 quality and the EOC. 

	 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. 

Scope 

The scope of the CAP review is limited. Serious issues that come to our attention that 

are outside the scope will be considered for further review separate from the CAP 

process and may be referred accordingly. 

For this review, we examined selected clinical and administrative activities to determine 

whether facility performance met requirements related to patient care quality and the 

EOC. In performing the review, we inspected selected areas, conversed with managers 

and employees, and reviewed clinical and administrative records. The review covered 

the following six activities: 

 QM 

 EOC 

 Medication Management 

	 Coordination of Care 

	 Acute Ischemic Stroke Care 

 MRI Safety 

We have listed the general information reviewed for each of these activities. Some of 

the items listed may not have been applicable to this facility because of a difference in 

size, function, or frequency of occurrence. 

The review covered facility operations for FY 2012, FY 2013, and FY 2014 through 

June 13, 2014, and was done in accordance with OIG standard operating procedures 

for CAP reviews. We also asked the facility to provide the status on the 

recommendations we made in our previous CAP report (Combined Assessment 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Providence VA Medical Center, Providence, RI 

Program Review of the Providence VA Medical Center, Providence, Rhode Island, 

Report No. 12-00708-171, April 27, 2012). 

During this review, we presented crime awareness briefings for 13 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. 

Additionally, we surveyed employees regarding patient safety and quality of care at the 

facility. An electronic survey was made available to all facility employees, and 

343 responded. We shared summarized results with facility managers. 

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 

Compensation and Pension 

By using the techniques of systems redesign and considering the Veterans Benefits 

Administration as one of its customers, the Compensation and Pension Department has 

significantly improved the timeliness and quality of exams. Department personnel have 

worked to decrease veteran claims processing times to a current average of 12 days. 

Daily communication between the two organizations has led to a constructive 

relationship that benefits veterans. This strong customer service effort has been 

recognized with an I Care Award from VISN 1 in 2013 and 2014 and a Gold Award from 

the VHA Office of Disability and Medical Assessment in 2014. 

Cancer Program 

The facility has one of two cancer programs in VISN 1 accredited by the American 

College of Surgeons’ Commission on Cancer. Accreditation requires the maintenance 

of a cancer registry, which is of great research value since data on veterans with cancer 

is not routinely submitted to state and national cancer registries. The facility registry is 

maintained by a Certified Tumor Registrar, and data is submitted to the commission in 

accordance with College of American Pathology protocols. A multidisciplinary cancer 

committee meets at least four times annually. Accreditation contributes to the quality of 

care for veterans by providing tumor boards; access to psychosocial, rehabilitation, and 

nutrition services; psychosocial distress screening; and survivorship care plans. 

Patients are also informed about clinical trials, and at least 2 percent of patients are 

enrolled in trials annually. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Providence VA Medical Center, Providence, RI 

Pathways to Excellence 

In March 2014, the facility became the second VA facility in the country to receive the 

American Nurses Credentialing Center Pathway to Excellence® designation, an 

accomplishment achieved by only 9 percent of hospitals nationwide. The designation 

recognizes positive practice environments where nurses excel and requires rigorous 

practice standards such as nursing control over nursing practice, a safe and healthy 

work environment, and systems to address patient care and practice concerns. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Providence VA Medical Center, Providence, RI 

Results and Recommendations 

QM 

The purpose of this review was to determine whether facility senior managers actively supported 

and appropriately responded to QM efforts and whether the facility met selected requirements 

within its QM program.a 

We conversed with senior managers and key QM employees, and we evaluated meeting 

minutes, EHRs, and other relevant documents. The table below shows the areas reviewed for 

this topic. The areas marked as NM did not meet applicable requirements and needed 

improvement. Any items that did not apply to this facility are marked NA. 

NM Areas Reviewed Findings 

There was a senior-level committee/group 

responsible for QM/performance improvement 

that met regularly. 

 There was evidence that outlier data was 

acted upon. 

 There was evidence that QM, patient 

safety, and systems redesign were 

integrated. 

X The protected peer review process met 

selected requirements: 

 The PRC was chaired by the Chief of Staff 

and included membership by applicable 

service chiefs. 

 Actions from individual peer reviews were 

completed and reported to the PRC. 

 The PRC submitted quarterly summary 

reports to the MEC. 

 Unusual findings or patterns were 

discussed at the MEC. 

Six months of PRC meeting minutes reviewed: 

 None of the six completed actions were 

reported to the PRC. 

Focused Professional Practice Evaluations for 

newly hired licensed independent practitioners 

were initiated and completed, and results 

were reported to the MEC. 

Specific telemedicine services met selected 

requirements: 

 Services were properly approved. 

 Services were provided and/or received by 

appropriately privileged staff. 

 Professional practice evaluation information 

was available for review. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Providence VA Medical Center, Providence, RI 

NM Areas Reviewed (continued) Findings 

Observation bed use met selected 

requirements: 

 Local policy included necessary elements. 

 Data regarding appropriateness of 

observation bed usage was gathered. 

 If conversions to acute admissions were 

consistently 30 percent or more, 

observation criteria and utilization were 

reassessed timely. 

Staff performed continuing stay reviews on at 

least 75 percent of patients in acute beds. 

X The process to review resuscitation events 

met selected requirements: 

 An interdisciplinary committee was 

responsible for reviewing episodes of care 

where resuscitation was attempted. 

 Resuscitation event reviews included 

screening for clinical issues prior to events 

that may have contributed to the 

occurrence of the code. 

 Data were collected that measured 

performance in responding to events. 

Twelve months of Special Care Committee 

meeting minutes reviewed: 

 There was no evidence that data were 

collected to measure performance in 

responding to events. 

X The surgical review process met selected 

requirements: 

 An interdisciplinary committee with 

appropriate leadership and clinical 

membership met monthly to review surgical 

processes and outcomes. 

 Surgical deaths with identified problems or 

opportunities for improvement were 

reviewed. 

 Additional data elements were routinely 

reviewed. 

 The Surgical Service Staff Committee only 

met 4 times over the past 6 months. 

Critical incidents reporting processes were 

appropriate. 

The process to review the quality of entries in 

the EHR met selected requirements: 

 A committee was responsible to review 

EHR quality. 

 Data were collected and analyzed at least 

quarterly. 

 Reviews included data from most services 

and program areas. 

The policy for scanning non-VA care 

documents met selected requirements. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Providence VA Medical Center, Providence, RI 

NM Areas Reviewed (Continued) Findings 

X The process to review blood/transfusions 

usage met selected requirements: 

 A committee with appropriate clinical 

membership met at least quarterly to review 

blood/transfusions usage. 

 Additional data elements were routinely 

reviewed. 

 The Blood Usage Review Committee only 

met twice in 12 months. 

Two months of Blood Usage Review Committee 

meeting minutes reviewed: 

 The review process did not include the results 

of proficiency testing and the results of peer 

reviews when transfusions did not meet 

criteria. 

X Overall, if significant issues were identified, 

actions were taken and evaluated for 

effectiveness. 

 Corrective actions were not consistently 

taken, implemented, and followed to 

resolution for surgical performance 

improvement activities, EHR quality reviews, 

and blood/transfusion review issues. 

Overall, senior managers were involved in 

performance improvement over the past 

12 months. 

Overall, the facility had a comprehensive, 

effective QM/performance improvement 

program over the past 12 months. 

The facility met any additional elements 

required by VHA or local policy. 

Recommendations 

1. We recommended that processes be strengthened to ensure that completed actions from 

peer reviews are reported to the Peer Review Committee. 

2. We recommended that processes be strengthened to ensure that the Special Care 

Committee collects data that measures performance in responding to codes. 

3. We recommended that the Surgical Service Staff Committee meet monthly. 

4. We recommended that processes be strengthened to ensure that the Blood Usage Review 

Committee meets at least quarterly and that the blood/transfusions usage review process 

includes the results of proficiency testing and the results of peer reviews when transfusions did 

not meet criteria. 

5. We recommended that processes be strengthened to ensure that when data analysis 

indicates problems or opportunities for improvement, actions are consistently identified, 

implemented, and followed to resolution in surgical performance improvement activities, 

electronic health record quality reviews, and blood/transfusion reviews. 

VA OIG Office of Healthcare Inspections 6 
 

 

 

CAP Review of the Providence VA Medical Center, Providence, RI 

EOC 

The purpose of this review was to determine whether the facility maintained a clean and safe 

health care environment in accordance with applicable requirements and whether the facility 

met selected requirements in SDS, the PACU, and the eye clinic.b 

We inspected the medical/surgical, telemetry, intensive care, and behavioral health inpatient 

units. We also inspected the emergency department; the inpatient pharmacy; the PACU; SDS; 

and the primary care, eye, dialysis, and women’s health clinics. Additionally, we reviewed 

relevant documents, conversed with key employees and managers, and reviewed 23 employee 

training records (11 SDS, 7 PACU, and 5 eye clinic). The table below shows the areas reviewed 

for this topic. The areas marked as NM did not meet applicable requirements and needed 

improvement. Any items that did not apply to this facility are marked NA. 

NM Areas Reviewed for General EOC Findings 

EOC Committee minutes reflected sufficient 

detail regarding identified deficiencies, 

corrective actions taken, and tracking of 

corrective actions to closure. 

An infection prevention risk assessment was 

conducted, and actions were implemented to 

address high-risk areas. 

Infection Prevention/Control Committee 

minutes documented discussion of identified 

problem areas and follow-up on implemented 

actions and included analysis of surveillance 

activities and data. 

X Environmental safety requirements were met.  Floors needed cleaning in seven of nine 

patient care areas and several public 

restrooms, and two of nine patient care areas 

had damaged floor tiles. 

 We found blood stained gauze and tape in the 

shower of an unoccupied patient room 

reported as terminally cleaned. 

 We found damaged furniture in three of nine 

patient care areas. 

 Surfaces around hand sinks in primary care 

exam rooms were worn or damaged to the 

point where they could not be effectively 

sanitized. 

 The pharmacy clean room for compounding 

sterile products was not compliant with United 

States Pharmacopeia <797>1

 cleanliness, 

sterility, and monitoring standards. 

1

 United States Pharmacopeia Chapter <797>, Pharmaceutical Compounding of Sterile Preparations, details the procedures and 

requirements for compounding sterile preparations and sets standards that are applicable to all practice settings in which sterile 

preparations are compounded. 

VA OIG Office of Healthcare Inspections 7 
 

CAP Review of the Providence VA Medical Center, Providence, RI 

NM Areas Reviewed for General EOC 

(continued) 

Findings 

Fire safety requirements were met. 

Infection prevention requirements were met. 

Medication safety and security requirements 

were met. 

Auditory privacy requirements were met. 

X The facility complied with any additional 

elements required by VHA, local policy, or 

other regulatory standards. 

Local policy on the EOC program reviewed: 

 The chairperson and other key members of 

the EOC Committee had limited or no 

attendance at committee meetings. 

 EOC rounds failed to adequately identify 

deficiencies related to general housekeeping 

and cleanliness. 

Local policy on the Security Management Plan 

reviewed: 

 The facility’s required annual Security 

Management Plan was last updated in 2012. 

 VA Police did not provide quarterly security 

reports to the EOC Committee. 

Areas Reviewed for SDS and the PACU 

Designated SDS and PACU employees 

received bloodborne pathogens training 

during the past 12 months. 

Designated SDS employees received medical 

laser safety training with the frequency 

required by local policy. 

Fire safety requirements in SDS and on the 

PACU were met. 

Environmental safety requirements in SDS 

and on the PACU were met. 

SDS medical laser safety requirements were 

met. 

Infection prevention requirements in SDS and 

on the PACU were met. 

Medication safety and security requirements 

in SDS and on the PACU were met. 

Auditory privacy requirements in SDS and on 

the PACU were met. 

The facility complied with any additional 

elements required by VHA, local policy, or 

other regulatory standards. 

Areas Reviewed for Eye Clinic 

Designated eye clinic employees received 

laser safety training with the frequency 

required by local policy. 

Environmental safety requirements in the eye 

clinic were met. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Providence VA Medical Center, Providence, RI 

NM Areas Reviewed for Eye Clinic (continued) Findings 

Infection prevention requirements in the eye 

clinic were met. 

Medication safety and security requirements 

in the eye clinic were met. 

Laser safety requirements in the eye clinic 

were met. 

The facility complied with any additional 

elements required by VHA, local policy, or 

other regulatory standards. 

Recommendations 

6. We recommended that processes be strengthened to ensure that all patient care areas and 

public restrooms are clean and that compliance be monitored. 

7. We recommended that processes be strengthened to ensure that procedures for terminal 

cleaning of patient rooms are followed and that compliance be monitored. 

8. We recommended that processes be strengthened to ensure that in patient care areas, 

damaged furniture is repaired or removed from service and damaged surfaces are repaired and 

that compliance be monitored. 

9. We recommended that the pharmacy clean room for compounding sterile products be 

brought into compliance with United States Pharmacopeia <797> cleanliness, sterility, and 

monitoring standards. 

10. We recommended that processes be strengthened to ensure that all required members of 

the Environment of Care Committee consistently attend committee meetings, that the program 

be strengthened to ensure effective surveillance activities, and that compliance be monitored. 

11. We recommended that processes be strengthened to ensure that VA Police update the 

facility’s Security Management Plan annually and submit quarterly security reports to the 

Environment of Care Committee. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Providence VA Medical Center, Providence, RI 

Medication Management 

The purpose of this review was to determine whether the appropriate clinical oversight and 

education were provided to patients discharged with orders for fluoroquinolone oral antibiotics.c 

We reviewed relevant documents and conversed with key managers and employees. 

Additionally, we reviewed the EHRs of 34 randomly selected inpatients discharged on 1 of 

3 selected oral antibiotics. The table below shows the areas reviewed for this topic. Any items 

that did not apply to this facility are marked NA. The facility generally met requirements. We 

made no recommendations. 

NM Areas Reviewed Findings 

Clinicians conducted inpatient learning 

assessments within 24 hours of admission or 

earlier if required by local policy. 

If learning barriers were identified as part of 

the learning assessment, medication 

counseling was adjusted to accommodate the 

barrier(s). 

Patient renal function was considered in 

fluoroquinolone dosage and frequency. 

Providers completed discharge progress 

notes or discharge instructions, written 

instructions were provided to 

patients/caregivers, and EHR documentation 

reflected that the instructions were 

understood. 

Patients/caregivers were provided a written 

medication list at discharge, and the 

information was consistent with the dosage 

and frequency ordered. 

Patients/caregivers were offered medication 

counseling, and this was documented in 

patient EHRs. 

The facility established a process for 

patients/caregivers regarding whom to notify 

in the event of an adverse medication event. 

The facility complied with any additional 

elements required by VHA or local policy. 

VA OIG Office of Healthcare Inspections 10 
 

CAP Review of the Providence VA Medical Center, Providence, RI 

Coordination of Care 

The purpose of this review was to evaluate discharge planning for patients with selected 

aftercare needs.d 

We reviewed relevant documents, and we conversed with key employees. Additionally, we 

reviewed the EHRs of 34 randomly selected patients with specific diagnoses who were 

discharged from July 1, 2012, through June 30, 2013. The table below shows the areas 

reviewed for this topic. Any items that did not apply to this facility are marked NA. The facility 

generally met requirements. We made no recommendations. 

NM Areas Reviewed Findings 

Patients’ post-discharge needs were 

identified, and discharge planning addressed 

the identified needs. 

Clinicians provided discharge instructions to 

patients and/or caregivers and validated their 

understanding. 

Patients received the ordered aftercare 

services and/or items within the 

ordered/expected timeframe. 

Patients’ and/or caregivers’ knowledge and 

learning abilities were assessed during the 

inpatient stay. 

The facility complied with any additional 

elements required by VHA or local policy. 

VA OIG Office of Healthcare Inspections 11 
 

CAP Review of the Providence VA Medical Center, Providence, RI 

Acute Ischemic Stroke Care 

The purpose of this review was to determine whether the facility complied with selected 

requirements for the assessment and treatment of patients who had an acute ischemic stroke.e 

We reviewed relevant documents, the EHRs of 19 patients who experienced stroke symptoms, 

and 15 employee training records (5 emergency department, 5 intensive care unit, and 5 acute 

inpatient unit), and we conversed with key employees. We also conducted onsite inspections of 

the emergency department, the intensive care unit, two acute inpatient units, and the mental 

health unit. The table below shows the areas reviewed for this topic. The areas marked as NM 

did not meet applicable requirements and needed improvement. Any items that did not apply to 

this facility are marked NA. 

NM Areas Reviewed Findings 

The facility’s stroke policy/plan/guideline 

addressed all required items. 

X Clinicians completed the National Institutes of 

Health stroke scale for each patient within the 

expected timeframe. 

 Four of the applicable 11 EHRs did not 

contain documented evidence of completed 

stroke scales. 

NA Clinicians provided medication (tissue 

plasminogen activator) timely to halt the 

stroke and included all required steps, and 

tissue plasminogen activator was in stock or 

available within 15 minutes. 

Stroke guidelines were posted in all areas 

where patients may present with stroke 

symptoms. 

X Clinicians screened patients for difficulty 

swallowing prior to oral intake of food or 

medicine. 

 Fourteen of the applicable 15 EHRs did not 

contain documentation that patients were 

screened for difficulty swallowing prior to oral 

intake. 

X Clinicians provided printed stroke education to 

patients upon discharge. 

 Seven of the applicable nine EHRs did not 

contain documentation that stroke education 

was provided to the patient/caregiver. 

The facility provided training to staff involved 

in assessing and treating stroke patients. 

The facility collected and reported required 

data related to stroke care. 

X The facility complied with any additional 

elements required by VHA or local policy. 

Facility policy required that PTT and PT/INR 

tests be completed for patients presenting with 

stroke symptoms. 

 Eight of the applicable 10 EHRs did not 

contain documented evidence that PTT 

and/or PT/INR tests were completed. 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Providence VA Medical Center, Providence, RI 

Recommendations 

12. We recommended that processes be strengthened to ensure that clinicians complete and 

document National Institutes of Health stroke scales for each stroke patient and that compliance 

be monitored. 

13. We recommended that processes be strengthened to ensure that clinicians screen patients 

for difficulty swallowing prior to oral intake. 

14. We recommended that processes be strengthened to ensure that clinicians provide printed 

stroke education to patients upon discharge and that compliance be monitored. 

15. We recommended that processes be strengthened to ensure that clinician assessment of 

patients presenting with stroke symptoms includes facility required PTT and PT/INR tests and 

that compliance be monitored. 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Providence VA Medical Center, Providence, RI 

MRI Safety 

The purpose of this review was to determine whether the facility ensured safety in MRI in 

accordance with VHA policy requirements related to: (1) staff safety training, (2) patient 

screening, and (3) risk assessment of the MRI environment.f 

We reviewed relevant documents and the training records of 41 employees (30 randomly 

selected Level 1 ancillary staff and 11 designated Level 2 MRI personnel), and we conversed 

with key managers and employees. We also reviewed the EHRs of 35 randomly selected 

patients who had an MRI January 1–December 31, 2013. Additionally, we conducted a physical 

inspection of the MRI area. The table below shows the areas reviewed for this topic. Any items 

that did not apply to this facility are marked NA. The facility generally met requirements. We 

made no recommendations. 

NM Areas Reviewed Findings 

The facility completed an MRI risk 

assessment, there were documented 

procedures for handling emergencies in MRI, 

and emergency drills were conducted in the 

MRI area. 

Two patient safety screenings were conducted 

prior to MRI, and the secondary patient safety 

screening form was signed by the patient, 

family member or caregiver and reviewed and 

signed by a Level 2 MRI personnel. 

Any MRI contraindications were noted on the 

secondary patient safety screening form, and 

a Level 2 MRI personnel and/or radiologist 

addressed the contraindications and 

documented resolution prior to MRI. 

Level 1 ancillary staff and Level 2 MRI 

personnel were designated and received 

level-specific annual MRI safety training. 

Signage and barriers were in place to prevent 

unauthorized or accidental access to Zones III 

and IV. 

MRI technologists maintained visual contact 

with patients in the magnet room and two-way 

communication with patients inside the 

magnet, and the two-way communication 

device was regularly tested. 

Patients were offered MRI-safe hearing 

protection for use during the scan. 

The facility had only MRI-safe or compatible 

equipment in Zones III and IV, or the 

equipment was appropriately protected from 

the magnet. 

The facility complied with any additional 

elements required by VHA or local policy. 

VA OIG Office of Healthcare Inspections 14 
 

 

CAP Review of the Providence VA Medical Center, Providence, RI 

Appendix A 

Facility Profile (Providence/650) FY 2014 through 

June 20142 

Type of Organization Secondary 

Complexity Level 2-Medium complexity 

Affiliated/Non-Affiliated Affiliated 

Total Medical Care Budget in Millions $225.9 

Number of: 

 Unique Patients 29,833 

 Outpatient Visits 273,789 

 Unique Employees3 1,101 

Type and Number of Operating Beds: 

 Hospital 73 

 Community Living Center NA 

 Mental Health 18 

Average Daily Census (as of May): 

 Hospital 50 

 Community Living Center NA 

 Mental Health 14 

Number of Community Based Outpatient Clinics 3 

Location(s)/Station Number(s) New Bedford/650GA 

Hyannis/650GB 

Middletown/650GD 

VISN Number 1 

2

 All data is for FY 2014 through June 2014 except where noted. 

3

 Unique employees involved in direct medical care (cost center 8200) from most recent pay period. 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Providence VA Medica

Strategic Analytics for Improvement and Learning (SAIL)4 

4 Metric definitions follow the graphs. 

VA OIG Office of Healthcare Inspections 
CAP Review of the Providence VA 

Scatter Chart 

VA OIG Office of Healthcare Inspections 
CAP Review of the Providence VA 

Metric Definitions 

Measure Definition Desired direction 

ACSC Hospitalization Ambulatory care sensitive condition hospitalizations (observed to expected ratio) A lower value is bett

Adjusted LOS Acute care risk adjusted length of stay A lower value is bett

Call Center Responsiveness Average speed of call center responded to calls in seconds A lower value is bett

Call Responsiveness Call center speed in picking up calls and telephone abandonment rate A lower value is bett

Complications Acute care risk adjusted complication ratio A lower value is bett

Efficiency Overall efficiency measured as 1 divided by SFA (Stochastic Frontier Analysis) A higher value is bet

Employee Satisfaction Overall satisfaction with job A higher value is bet

HC Assoc Infections Health care associated infections A lower value is bett

HEDIS Outpatient performance measure (HEDIS) A higher value is bet

Mental Health Status Mental health status (outpatient only, the Veterans RAND 12 Item Health Survey) A higher value is bet

Mental Health Wait Time Mental health wait time for new and established patients (top 50 clinics) A higher value is bet

Oryx Inpatient performance measure (ORYX) A higher value is betPhysical Health Status Physical health status (outpatient only, the Veterans RAND 12 item Health Survey) A higher value is bet

Primary Care Wait Time Primary care wait time for new and established patients (top 50 clinics) A higher value is bet

PSI Patient safety indicator A lower value is bett

Pt Satisfaction Overall rating of hospital stay (inpatient only) A higher value is bet

RN Turnover Registered nurse turnover rate A lower value is bett

RSMR-AMI 30-day risk standardized mortality rate for acute myocardial infarction A lower value is bett

RSMR-CHF 30-day risk standardized mortality rate for congestive heart failure A lower value is bett

RSMR-Pneumonia 30-day risk standardized mortality rate for pneumonia A lower value is bett

RSRR-AMI 30-day risk standardized readmission rate for acute myocardial infarction A lower value is bett

RSRR-CHF 30-day risk standardized readmission rate for congestive heart failure A lower value is bett

RSRR-Pneumonia 30-day risk standardized readmission rate for pneumonia A lower value is bett

SMR Acute care in-hospital standardized mortality ratio A lower value is bett

SMR30 Acute care 30-day standardized mortality ratio A lower value is bett

Specialty Care Wait Time Specialty care wait time for new and established patients (top 50 clinics) A higher value is bet

VA OIG Office of Healthcare Inspections 
 

CAP Review of the Providence VA Medical Center, Providence, RI 

Appendix C 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 8, 2014 

From: Director, VA New England Healthcare System (10N1) 

Subject: CAP Review of the Providence VA Medical Center 

Providence, RI 

To: Director, Bedford Office of Healthcare Inspections (54BN) 

Director, Management Review Service (VHA 10AR MRS 

OIG CAP CBOC) 

I have reviewed and concur with the action plans regarding the CAP 

Review of the Providence VA Medical Center, Providence, RI
 

June 14, 2014. 

Sincerely, 

Michael F. Mayo-Smith, MD, MPH 

Network Director 

VA OIG Office of Healthcare Inspections 19 
 

CAP Review of the Providence VA Medical Center, Providence, RI 

Appendix D 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 6, 2014 

From: Director, Providence VA Medical Center (650/00) 

Subject: CAP Review of the Providence VA Medical Center 

Providence, RI 

To: Director, VA New England Healthcare System (10N1) 

I have reviewed and concur with the action plans regarding the CAP 

Review of the Providence VA Medical Center, Providence, RI
 

June 14, 2014. 

Sincerely, 

VA OIG Office of Healthcare Inspections 20 
CAP Review of the Providence VA Medical Center, Providence, RI 

Comments to OIG’s Report 

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

in the OIG report: 

OIG Recommendations 

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

completed actions from peer reviews are reported to the Peer Review Committee. 

Concur 

Target date for completion: November 1, 2014 

Facility response: A plan to improve and revise the peer review process was 

implemented beginning in May 2014. When the Peer Review Committee assigns a 

Level 2 or Level 3, the committee through the Chief of Staff’s office will send a letter to 

the service chief and request that an action plan be identified and implemented in 

collaboration with the provider involved. The Committee will track the level 2 and 

3 action plan assignments through a facility developed tool. Once action is completed it 

will be reported back to the Peer Review Committee for closing. The process will be 

tracked until November 2014. 

Recommendation 2. We recommended that processes be strengthened to ensure that 

the Special Care Committee collects data that measures performance in responding to 

codes. 

Concur 

Target date for completion: September 1, 2014. 

Facility response: An interdisciplinary committee (Special Care Committee) is 

responsible for reviewing episodes of care where resuscitation was attempted. 

Beginning at the June meeting of the Special Care Committee, all codes were reviewed, 

brief discussion ensued and information included in the committee minutes. This 

information is tracked in a database and data aggregated over the course of the fiscal 

year. 

Recommendation 3. We recommended that the Surgical Service Staff Committee 

meet monthly. 

Concur 

Target date for completion: October 1, 2014. 

VA OIG Office of Healthcare Inspections 21 
 

CAP Review of the Providence VA Medical Center, Providence, RI 

Facility response: The Surgical Work Group Committee has been retooled to better 

align with the directive requirements to meet monthly. Since May, 2014 the committee 

has met monthly and monthly meetings have been established going forward. 

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

the Blood Usage Review Committee meets at least quarterly and that the 

blood/transfusions usage review process includes the results of proficiency testing and 

the results of peer reviews when transfusions did not meet criteria. 

Concur 

Target date for completion: November 1, 2014. 

Facility response: The Blood Usage Committee members have been reeducated 

regarding their responsibilities per committee policy. Quarterly meetings have been 

scheduled and the standard agenda includes all elements to be reviewed per policy. 

The proficiency testing report will now be included as an agenda item in the committee. 

Peer reviews results when transfusions do not meet criteria will also be reported at this 

committee though there have not been any occurrences this fiscal year. 

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

when data analysis indicates problems or opportunities for improvement, actions are 

consistently identified, implemented, and followed to resolution in surgical performance 

improvement activities, electronic health record quality reviews, and blood/transfusion 

reviews. 

Concur 

Target date for completion: November 1, 2014. 

Facility response: As stated above in number 4. These committees have been 

reeducated regarding their responsibilities per their individual committee policies 

regarding any corrective actions to be implemented and the need to follow thru to 

completion and note in the respective minutes. The minutes for these committees will 

be monitored for three months to ensure compliance. 

Recommendation 6. We recommended that processes be strengthened to ensure that 

all patient care areas and public restrooms are clean and that compliance be monitored. 

Concur 

Target date for completion: December 1, 2014. 

Facility response: A restoration contractor was hired in July, 2014 to bring all areas up 

to healthcare building standards of cleanliness. It is anticipated that the contract work 

will take up to 120 days. The hiring of twenty additional Housekeeping Aids has been 

authorized and recruitment is open and continuous. Restrooms are monitored hourly 

for cleanliness and a sign in sheet appears in each. Sheets will be retained and 

VA OIG Office of Healthcare Inspections 22 
 

CAP Review of the Providence VA Medical Center, Providence, RI 

summary provided to the EOC committee and Quality Management on a monthly basis. 

Also hiring progress to be monitored and updates presented at EOC committee. 

The facility has begun the process of reorganizing Environmental Management Services 

out of FMS and will formalize EMS as an independent service with direct oversight by 

the Associate Director of Operations. Human Resources is in the process of formally 

separating out the service, creating levels of service leadership, support staff and 

training positions. The reorganization of EMS is expected to provide the facility with a 

strong emphasis on EOC oversight. Target date for completion is 150 days as 

recruitment will need to occur. 

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

procedures for terminal cleaning of patient rooms are followed and that compliance be 

monitored. 

Concur 

Target date for completion: November 1, 2014. 

Facility response: Supervisors will monitor all rooms following a terminal cleaning, 

document compliance and provide summary report monthly at EOC Committee and to 

Quality Management. A full time training position for Housekeeping Aids is being 

created and will be recruited for. A separate room is being set aside for training of 

housekeepers in terminal cleaning of patient rooms. 

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

in patient care areas, damaged furniture is repaired or removed from service and 

damaged surfaces are repaired and that compliance be monitored. 

Concur 

Target date for completion: November 1, 2014. 

Facility response: Damaged furniture has been replaced and damaged surfaces have 

been repaired. Clarification of process owner’s responsibility to report damaged 

furniture and damaged wall surfaces has been established. Furniture is routinely 

inspected by EMS during cleaning and damaged furniture replaced. During EOC 

weekly rounds the EMS person will inspect the area being reviewed for any damaged 

furniture and damaged wall surfaces. 

Recommendation 9. We recommended that the pharmacy clean room for 

compounding sterile products be brought into compliance with United States 

Pharmacopeia <797> cleanliness, sterility, and monitoring standards. 

Concur 

Target date for completion: February 1, 2015 for permanent <797> ISO 7 compliant 

room. 

VA OIG Office of Healthcare Inspections 23 
CAP Review of the Providence VA Medical Center, Providence, RI 

Facility response: The facility is preparing temporary locations for pharmacy’s clean 

room operations while we await funding to build the approved permanent <797> fully 

compliant clean room for the Inpatient Pharmacy. In the interim, preparation of 

chemotherapy agents will be conducted in a <797> compliant IV trailer using certified 

negative pressure isolator (ISO 5). The sterile compounding of the other parenteral 

products will use a certified positive pressure isolator (ISO 5). This isolator is located in 

a separate and dedicated clean room. It is anticipated that the temporary facilities will 

be in use within 60 days followed by completion of the permanent facilities in 

February 2015. Environmental/biological testing and monitoring will commence upon 

awarding of a contract with an outside monitoring service. 

Recommendation 10. We recommended that processes be strengthened to ensure 

that all required members of the Environment of Care Committee consistently attend 

committee meetings, that the program be strengthened to ensure effective surveillance 

activities, and that compliance be monitored. 

Concur 

Target date for completion: November 1, 2014. 

Facility response: Reestablished oversight by the Chief of Facility Management Service 

and the Associate Director is providing supervision and direction for the EOC 

Committee to ensure compliance with components of the Environment of Care 

Committee policy and Directives. 

Recommendation 11. We recommended that processes be strengthened to ensure 

that VA Police update the facility’s Security Management Plan annually and submit 

quarterly security reports to the Environment of Care Committee. 

Concur 

Target date for completion: November 1, 2014. 

Facility response: Reestablished oversight by the Chief of Facility Management Service 

and the Associate Director is providing supervision and direction to ensure compliance 

with components of the Environment of Care Committee policy and Directives. The 

Security Management Plan will be reviewed and a standard report template for the 

Police Service was developed to report to the EOC Committee on a quarterly basis. 

Recommendation 12. We recommended that processes be strengthened to ensure 

that clinicians complete and document National Institutes of Health stroke scales for 

each stroke patient and that compliance be monitored. 

Concur 

Target date for completion: November 1, 2014. 

VA OIG Office of Healthcare Inspections 24 
CAP Review of the Providence VA Medical Center, Providence, RI 

Facility response: The Clinicians were reeducated and they will be completing the 

stroke template. All records will be monitored for compliance and outcome reported at 

Stroke Committee and to Quality Management. 

Recommendation 13. We recommended that processes be strengthened to ensure 

that clinicians screen patients for difficulty swallowing prior to oral intake. 

Concur 

Target date for completion: November 1, 2014. 

Facility response: This requirement was added to the nursing stroke/TIA template which 

will facilitate capturing the information in a standardized mode. The standard operating 

procedure dysphagia screening was developed and accepted. All nursing personnel 

were educated by May 30, 2014. All records will be monitored for three months to 

ensure compliance. 

Recommendation 14. We recommended that processes be strengthened to ensure 

that clinicians provide printed stroke education to patients upon discharge and that 

compliance be monitored. 

Concur 

Target date for completion: November 1, 2014. 

Facility response: This requirement was added to the nursing stroke/TIA assessment 

template to ensure compliance. All records will be monitored for three months to ensure 

compliance. 

Recommendation 15. We recommended that processes be strengthened to ensure 

that clinician assessment of patients presenting with stroke symptoms includes facility 

required PTT and PT/INR tests and that compliance be monitored. 

Concur 

Target date for completion: November 1, 2014. 

Facility response: The physician order set was edited to include PTT and all clinicians 

were reeducated. We will monitor for three months to ensure compliance. 

VA OIG Office of Healthcare Inspections 25 
CAP Review of the Providence VA Medical Center, Providence, RI 

Appendix E 

OIG Contact and Staff Acknowledgments 

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

at (202) 461-4720. 

Onsite Frank Keslof, EMT, MHA Team Leader 

Contributors Annette Acosta, RN, MN 

Elaine Kahigian, RN, JD 

Jeanne Martin, PharmD 

Jason Kravetz, Special Agent, Office of Investigations 

Other 

Contributors 

Elizabeth Bullock 

Shirley Carlile, BA 

Paula Chapman, CTRS 

Lin Clegg, PhD 

Marnette Dhooghe, MS 

Jeff Joppie, BS 

Nathan McClafferty, MS 

Patrick Smith, M. Stat 

Julie Watrous, RN, MS 

Jarvis Yu, MS 

VA OIG Office of Healthcare Inspections 26 
CAP Review of the Providence VA Medical Center, Providence, RI 

Appendix F 

Report Distribution 

VA Distribution 

Office of the Secretary 

VHA 

Assistant Secretaries 

General Counsel 

Director, VA New England Healthcare System (10N1) 

Director, Providence VA Medical Center (650/00) 

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: Jack Reed, Sheldon Whitehouse 

U.S. House of Representatives: David Cicilline, Jim Langevin 

This report is available at www.va.gov/oig. 

VA OIG Office of Healthcare Inspections 27 
 

 

 

 

 

 

 

 

CAP Review of the Providence VA Medical Center, Providence, RI 

Appendix G 

Endnotes 

a

 References used for this topic included: 

	 VHA Directive 2009-043, Quality Management System, September 11, 2009. 

	 VHA Handbook 1050.01, VHA National Patient Safety Improvement Handbook, March 4, 2011. 

	 VHA Directive 2010-017, Prevention of Retained Surgical Items, April 12, 2010. 

	 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010. 

	 VHA Directive 2010-011, Standards for Emergency Departments, Urgent Care Clinics, and Facility Observation 

Beds, March 4, 2010. 

	 VHA Directive 2009-064, Recording Observation Patients, November 30, 2009. 

	 VHA Handbook 1100.19, Credentialing and Privileging, October 15, 2012. 

	 VHA Directive 2008-063, Oversight and Monitoring of Cardiopulmonary Resuscitative Events and Facility 

Cardiopulmonary Resuscitation Committees, October 17, 2008. 

	 VHA Handbook 1907.01, Health Information Management and Health Records, September 19, 2012. 

	 VHA Directive 6300, Records Management, July 10, 2012. 

	 VHA Directive 2009-005, Transfusion Utilization Committee and Program, February 9, 2009. 

	 VHA Handbook 1106.01, Pathology and Laboratory Medicine Service Procedures, October 6, 2008. b

 References used for this topic included: 

	 VHA Directive 2011-007, Required Hand Hygiene Practices, February 16, 2011. 

	 VHA Handbook 1121.01, VHA Eye Care, March 10, 2011. 

	 VA National Center for Patient Safety, “Multi-Dose Pen Injectors,” Patient Safety Alert 13-04, January 17, 2013. 

	 “Adenovirus-Associated Epidemic Keratoconjunctivitis Outbreaks –Four States, 2008–2010,” Centers for Disease 

Control and Prevention Morbidity and Mortality Weekly Report, August 16, 2013. 

	 Various requirements of The Joint Commission, the Occupational Safety and Health Administration, the 

American National Standards Institute/Advancing Safety in Medical Technology, the Centers for Disease Control 

and Prevention, the International Association of Healthcare Central Service Materiel Management ,the National 

Fire Protection Association, the Health Insurance Portability and Accountability Act, Underwriters Laboratories. c

 References used for this topic included: 

	 VHA Handbook 1108.06, Inpatient Pharmacy Services, June 27, 2006. 

	 VHA Handbook 1108.05, Outpatient Pharmacy Services, May 30, 2006. 

	 VHA Directive 2011-012, Medication Reconciliation, March 9, 2011. 

	 VHA Handbook 1907.01, Health Information Management and Health Records, September 19, 2012. 

	 Manufacturer’s instructions for Cipro® and Levaquin®. 

	 Various requirements of The Joint Commission. d

 References used for this topic included: 

	 VHA Handbook 1120.04, Veterans Health Education and Information Core Program Requirements, 

July 29, 2009. 

	 VHA Handbook 1907.01, Health Information Management and Health Records, September 19, 2012. 

	 The Joint Commission, Comprehensive Accreditation Manual for Hospitals, July 2013. e

 The references used for this topic were: 

	 VHA Directive 2011-038, Treatment of Acute Ischemic Stroke, November 2, 2011. 

	 Guidelines for the Early Management of Patients with Acute Ischemic Stroke (AHA/ASA Guidelines), 

January 31, 2013. f

 References used for this topic included: 

	 VHA Handbook 1105.05, Magnetic Resonance Imaging Safety, July 19, 2012. 

	 Emanuel Kanal, MD, et al., “ACR Guidance Document on MR Safe Practices: 2013,” Journal of Magnetic 

Resonance Imaging, Vol. 37, No. 3, January 23, 2013, pp. 501–530. 

	 The Joint Commission, “Preventing accidents and injuries in the MRI suite,” Sentinel Event Alert, Issue 38, 

February 14, 2008. 

	 VA National Center for Patient Safety, “MR Hazard Summary,” 

http://www.patientsafety.va.gov/professionals/hazards/mr.asp. 

	 VA Radiology, “Online Guide,” http://vaww1.va.gov/RADIOLOGY/OnLine_Guide.asp, updated 

October 4, 2011. 

VA OIG Office of Healthcare Inspections 28