Department of Veterans Affairs

Office of Inspector General 

Office of Healthcare Inspections 

Report No. 14-02069-268 

Combined Assessment Program 

Review of the 

John D. Dingell VA Medical Center 

Detroit, Michigan 

September 4, 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 John D. Dingell VA Medical Center, Detroit, MI 

Glossary 

CAP Combined Assessment Program 

CLC community living center 

EHR electronic health record 

EOC environment of care 

facility John D. Dingell VA Medical Center 

FY fiscal year 

MEC Medical Executive Committee 

MH mental health 

MRI magnetic resonance imaging 

NA not applicable 

NM not met 

OIG Office of Inspector General 

PACU post-anesthesia care unit 

PRC Peer Review Committee 

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 John D. Dingell VA Medical Center, Detroit, MI 

Table of Contents 

Page 

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

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

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

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

Results and Recommendations................................................................................ 3
 

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

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

Medication Management......................................................................................... 8
 

Coordination of Care ............................................................................................... 9
 

Acute Ischemic Stroke Care ................................................................................... 10
 

CLC Resident Independence and Dignity ............................................................... 12
 

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

Appendixes 

A. Facility Profile .................................................................................................... 16
 

B. Strategic Analytics for Improvement and Learning ............................................ 17
 

C. VISN Director Comments .................................................................................. 20
 

D. Facility Director Comments ............................................................................... 21
 

E. OIG Contact and Staff Acknowledgments ......................................................... 30
 

F. Report Distribution ............................................................................................. 31
 

G. Endnotes ........................................................................................................... 32
 

VA OIG Office of Healthcare Inspections 
 

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

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 

July 14, 2014. 

Review Results: The review covered seven activities. We made no 

recommendations in the following activity: 

 Coordination of Care 

Recommendations: We made recommendations in the following six activities: 

Quality Management: Ensure the Blood Usage Review Committee member from 

Anesthesia Service consistently attends meetings. 

Environment of Care: Secure medication carts at all times. Maintain auditory privacy in 

all intake areas, and stress to staff that sensitive patient information should not be 

discussed in public areas. Ensure all designed eye clinic employees receive eye laser 

safety training with the frequency required by local policy. 

Medication Management: Document patient/caregiver understanding of discharge 

instructions. 

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

stroke scales for each stroke patient. Screen patients for swallowing difficulties prior to 

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

involved in assessing and treating stroke patients receive the training required by the 

facility. 

Community Living Center Resident Independence and Dignity: Complete and 

document restorative nursing services according to clinician orders and/or residents’ 

care plans. Modify restorative nursing interventions as needed, and document the 

modifications. Document the reasons for not providing restorative nursing services 

when those services are care planned. Ensure hand-off communication occurs 

between Physical Medicine and Rehabilitation Service and the community living center 

when residents are discharged from therapy. Require that staff who perform restorative 

nursing services receive training on range of motion and resident transfers. Document 

residents’ restorative progress weekly. 

Magnetic Resonance Imaging Safety: Conduct initial patient safety screenings. Ensure 

radiologists and/or Level 2 magnetic resonance imaging personnel document resolution 

of all contraindications prior to the scan. Require that all designated Level 1 ancillary 

staff and Level 2 magnetic resonance imaging personnel receive annual level-specific 

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

magnetic resonance imaging safety training. Regularly test two-way communication 

devices. 

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, page 20–29, 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 John D. Dingell VA Medical Center, Detroit, MI 

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 seven activities: 

 QM 

 EOC 

 Medication Management 

	 Coordination of Care 

	 Acute Ischemic Stroke Care 

	 CLC Resident Independence and Dignity 

 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 FYs 2011–2013 and FY 2014 through 

July 14, 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 

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

we made in our previous CAP report (Combined Assessment Program Review of the 

John D. Dingell VA Medical Center, Detroit, Michigan, Report No. 12-02600-28, 

November 8, 2012). 

During this review, we presented crime awareness briefings for 144 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 

305 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. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

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 area 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. 

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. 

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 3 
 

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

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. 

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. 

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. 

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 4 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

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. 

Eight months of Blood Usage Review 

Committee meeting minutes reviewed: 

 The clinical representative from Anesthesia 

Service attended only two of eight meetings. 

Overall, if significant issues were identified, 

actions were taken and evaluated for 

effectiveness. 

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. 

Recommendation 

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

Committee member from Anesthesia Service consistently attends meetings. 

VA OIG Office of Healthcare Inspections 5 
  

 

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

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 emergency department, the CLC, the intensive care unit, the inpatient MH 

unit, the medical unit, the surgical unit, SDS, the PACU, and the eye clinic. Additionally, we 

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

31 employee training records (16 SDS, 10 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. 

Fire safety requirements were met. 

Environmental safety requirements were met. 

Infection prevention requirements were met. 

X Medication safety and security requirements 

were met. 

 There were unlocked medication carts in 

three of six patient care areas. 

X Auditory privacy requirements were met.  The intake area in one of six patient care 

areas did not have sufficient auditory privacy, 

and sensitive patient information was 

discussed in a facility public area. 

The facility complied with any additional 

elements required by VHA, local policy, or 

other regulatory standards. 

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. 

VA OIG Office of Healthcare Inspections 6 
 

 

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

NM Areas Reviewed for SDS and the PACU 

(continued) 

Findings 

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 

X Designated eye clinic employees received 

laser safety training with the frequency 

required by local policy. 

 Two of the five eye clinic employees did not 

receive laser safety training with the 

frequency required by local policy. 

Environmental safety requirements in the eye 

clinic were met. 

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 

2. We recommended that processes be strengthened to ensure that medication carts are 

secured at all times and that compliance be monitored. 

3. We recommended that processes be strengthened to ensure that auditory privacy is 

maintained in all intake areas, that managers stress to staff that sensitive patient information 

should not be discussed in public areas, and that compliance be monitored. 

4. We recommended that processes be strengthened to ensure that all designated eye clinic 

employees receive eye laser safety training with the frequency required by local policy and that 

compliance be monitored. 

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

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 33 randomly selected inpatients discharged on 1 of 

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

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 

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. 

X Providers completed discharge progress 

notes or discharge instructions, written 

instructions were provided to 

patients/caregivers, and EHR documentation 

reflected that the instructions were 

understood. 

 Eight EHRs (24 percent) did not reflect that 

patients/caregivers understood discharge 

instructions. 

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. 

Recommendation 

5. We recommended that processes be strengthened to ensure that clinicians document 

patient/caregiver understanding of discharge instructions and that compliance be monitored. 

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

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 conversed with key employees. Additionally, we 

reviewed the EHRs of 29 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 9 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

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 31 randomly selected patients who experienced 

stroke symptoms, and 15 staff training records (5 emergency department, 5 intensive care unit, 

and 5 medical and step-down unit), and we conversed with key employees. We also conducted 

onsite inspections of the emergency department/urgent care unit, one critical care unit, and two 

acute inpatient units. 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. 

 Twenty-five EHRs (81 percent) did not contain 

documented evidence of completed stroke 

scales. 

Clinicians provided 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. 

 Fifteen EHRs (48 percent) 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. 

 Fourteen EHRs (45 percent) did not contain 

documentation that stroke education was 

provided to the patient/caregiver. 

X The facility provided training to staff involved 

in assessing and treating stroke patients. 

 Two employees had not completed the 

web-based training required by the facility. 

The facility collected and reported required 

data related to stroke care. 

The facility complied with any additional 

elements required by VHA or local policy. 

Recommendations 

6. 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. 

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

for difficulty swallowing prior to oral intake. 

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

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

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

9. We recommended that processes be strengthened to ensure that employees who are 

involved in assessing and treating stroke patients receive the training required by the facility and 

that compliance be monitored. 

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

CLC Resident Independence and Dignity 

The purpose of this review was to determine whether the facility provided CLC restorative 

nursing services and complied with selected nutritional management and dining service 

requirements to assist CLC residents in maintaining their optimal level of functioning, 

independence, and dignity.f 

We reviewed 14 EHRs of residents (10 residents receiving restorative nursing services and 

4 residents not receiving restorative nursing services but candidates for services). We also 

observed 2 meal periods, reviewed 10 employee training/competency records and other 

relevant documents, and conversed with key employees. 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 offered restorative nursing 

services. 

X Facility staff completed and documented 

restorative nursing services, including active 

and passive range of motion, bed mobility, 

transfer, and walking activities, according to 

clinician orders and residents’ care plans. 

 None of the 10 applicable EHRs contained 

documentation that facility staff completed 

restorative nursing services according to 

clinician orders and/or residents’ care plans. 

X Resident progress towards restorative nursing 

goals was documented, and interventions 

were modified as needed to promote the 

resident’s accomplishment of goals. 

 Neither of the two applicable EHRs contained 

evidence that facility staff documented that 

interventions were modified to promote the 

residents’ accomplishment of goals. 

X When restorative nursing services were care 

planned but were not provided or were 

discontinued, reasons were documented in 

the EHR. 

 None of the 10 applicable EHRs where 

restorative nursing services were care 

planned but were not provided reflected the 

reasons. 

X If residents were discharged from physical 

therapy, occupational therapy, or 

kinesiotherapy, there was hand-off 

communication between Physical Medicine 

and Rehabilitation Service and the CLC to 

ensure that restorative nursing services 

occurred. 

 Neither of the two EHRs of residents who 

were discharged from one of the therapies 

reflected hand-off communication. 

X Training and competency assessment were 

completed for staff who performed restorative 

nursing services. 

 Two employee training records did not 

contain evidence of completed training for 

range of motion and resident transfers. 

X The facility complied with any additional 

elements required by VHA or local policy. 

Local policy on restorative care program for CLC 

residents reviewed: 

 Although local policy required weekly 

documentation of residents’ restorative 

progress, 4 of the 10 applicable EHRs lacked 

these weekly notes. 

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

NM Areas Reviewed for Assistive Eating 

Devices and Dining Service 

Findings 

NA Care planned/ordered assistive eating devices 

were provided to residents at meal times. 

Required activities were performed during 

resident meal periods. 

The facility complied with any additional 

elements required by VHA or local policy. 

Recommendations 

10. We recommended that processes be strengthened to ensure that staff complete and 

document restorative nursing services according to clinician orders and/or residents’ care plans 

and that compliance be monitored. 

11. We recommended that processes be strengthened to ensure that staff modify restorative 

nursing interventions as needed and document the modifications and that compliance be 

monitored. 

12. We recommended that processes be strengthened to ensure that staff document the 

reasons for not providing restorative nursing services when those services are care planned and 

that compliance be monitored. 

13. We recommended that processes be strengthened to ensure that hand-off communication 

occurs between Physical Medicine and Rehabilitation Service and the community living center 

when residents are discharged from therapy to ensure that restorative nursing services occur. 

14. We recommended that processes be strengthened to ensure that employees who perform 

restorative nursing services receive training on range of motion and resident transfers. 

15. We recommended that processes be strengthened to ensure that staff document residents’ 

restorative progress weekly and that compliance be monitored. 

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

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.g 

We reviewed relevant documents and the training records of 39 employees (27 randomly 

selected Level 1 ancillary staff and 12 designated Level 2 MRI personnel), and we conversed 

with key managers and employees. We also reviewed the EHRs of 34 randomly selected 

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

inspections of two MRI areas. 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 completed an MRI risk 

assessment, there were documented 

procedures for handling emergencies in MRI, 

and emergency drills were conducted in the 

MRI area. 

X 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. 

 Twenty-two EHRs (65 percent) did not contain 

initial patient safety screenings. 

X 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. 

 Eighteen of the 21 applicable EHRs did not 

contain documentation that all identified 

contraindications were addressed prior to 

MRI. 

X Level 1 ancillary staff and Level 2 MRI 

personnel were designated and received 

level-specific annual MRI safety training. 

 None of the Level 1 ancillary staff received 

level-specific annual MRI safety training. 

 Five Level 2 MRI personnel did not receive 

level-specific annual MRI safety training. 

Signage and barriers were in place to prevent 

unauthorized or accidental access to Zones III 

and IV. 

X 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. 

 In one of two MRI suites, facility staff did not 

regularly test the two-way communication 

device. 

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. 

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

NM Areas Reviewed (continued) Findings 

The facility complied with any additional 

elements required by VHA or local policy. 

Recommendations 

16. We recommended that processes be strengthened to ensure that initial patient safety 

screenings are conducted and that compliance be monitored. 

17. We recommended that processes be strengthened to ensure that radiologists and/or 

Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic 

health records of all identified magnetic resonance imaging contraindications prior to the scan 

and that compliance be monitored. 

18. We recommended that processes be strengthened to ensure that all designated 

Level 1 ancillary staff and Level 2 magnetic resonance imaging personnel receive annual 

level-specific magnetic resonance imaging safety training and that compliance be monitored. 

19. We recommended that processes be strengthened to ensure that two-way communication 

devices are regularly tested and that compliance be monitored. 

VA OIG Office of Healthcare Inspections 15 
 

 

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

Appendix A 

Facility Profile (Detroit/553) FY 2014 through June 20141 

Type of Organization Secondary 

Complexity Level 1b-High complexity 

Affiliated/Non-Affiliated Affiliated 

Total Medical Care Budget in Millions $315.2 

Number (as of July 2014) of: 

 Unique Patients 44,454 

 Outpatient Visits 399,765 

 Unique Employees2 1,530 

Type and Number of Operating Beds: 

 Hospital 100 

 CLC 109 

 MH 50 

Average Daily Census: 

 Hospital 60 

 CLC 69 

 MH 35 

Number of Community Based Outpatient Clinics 2 

Location(s)/Station Number(s) Yale/553GA 

Pontiac/553GB 

VISN Number 11 

1

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

2

 Unique employees involved in direct medical care (cost center 8200). 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the John D. Dingell VA Me

Strategic Analytics for Improvement and Learning (SAIL)3

3 Metric definitions follow the graphs. 

VA OIG Office of Healthcare Inspections 
CAP Review of the John D. Dinge

Scatter Chart 

VA OIG Office of Healthcare Inspections 
CAP Review of the John D. Dinge

Metric Definitions 

Measure Definition Desired direc

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

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

Best Place to Work Overall satisfaction with job A higher value 

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

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

Complications Acute care risk adjusted complication ratio A lower value 

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

Employee Satisfaction Overall satisfaction with job A higher value 

HC Assoc Infections Health care associated infections A lower value 

HEDIS Outpatient performance measure (HEDIS) A higher value 

MH Status MH status (outpatient only, the Veterans RAND 12 Item Health Survey) A higher value 

MH Wait Time MH wait time for new and established patients (top 50 clinics; FY13 and later) A higher value 

Oryx Inpatient performance measure (ORYX) A higher value 

Physical Health Status Physical health status (outpatient only, the Veterans RAND 12 item Health Survey) A higher value 

Primary Care Wait Time Primary care wait time for new and established patients (top 50 clinics; FY13 and later) A higher value 

PSI Patient safety indicator (observed to expected ratio) A lower value 

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

RN Turnover Registered nurse turnover rate A lower value 

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

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

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

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

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

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

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

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

Specialty Care Wait Time Specialty care wait time for new and established patients (top 50 clinics; FY13 and later) A higher value 

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

Appendix C 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 20, 2014 

From: Director, Veterans In Partnership (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 10AR MRS 

OIG CAP CBOC) 

1. Per your request, attached is the response to the draft CAP report for

the John D. Dingell VA Medical Center. I have reviewed the comments

and concur with the responses and actions to the recommendations in

the report.

2. If you have any questions, please contact Carol Jones, Chief Quality,

Safety and Values Officer, Veterans In Partnership, VISN 11 at

734-222-4302.

Paul Bockelman, FACHE 

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

Appendix D 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 20, 2014 

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 (10N11) 

1. Thank you for the opportunity to review the draft Office of Inspector 

General’s report on the John D. Dingell VA Medical Center CAP 

Review. I have reviewed each recommendation and concur with the 

findings. 

2. If you have any questions or wish to discuss this report, please contact 

me at (313) 576-1212. 

Pamela J. Reeves, MD, 

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

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 

the Blood Usage Review Committee member from Anesthesia Service consistently 

attends meetings. 

Concur 

Target date for completion: June 20, 2015 

Facility response: Anesthesia Service has assigned two staff members, a primary and 

alternate member, to the Blood Usage Review Committee. The Chair of the Committee 

will contact both Anesthesia Service members by email prior to the scheduled meetings 

which are held every other month. If the Anesthesia Service members do not respond, 

the committee chair will contact the members by phone and escalate the email 

notification simultaneously to the Chief of Anesthesia, Chief of Surgery and Chief of 

Staff. Six months of meetings will be monitored from 8-15-14 to 6-20-15. Each meeting 

will have minutes with an attached attendance sheet. Minutes are reviewed quarterly in 

the Quality Leadership Committee. 

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

medication carts are secured at all times and that compliance be monitored. 

Concur 

Target date for completion: February 2, 2015 

Facility response: The medication cart on the locked Psychiatric Unit required a battery 

which was replaced on 7-18-14 and all drawers are now able to lock. The medication 

cart on the acute surgical floor was repaired by replacing a latch on 8-12-14. The 

medication cart drawers in the Community Living Center (CLC) were left open by the 

nurse and the CNM has reviewed medication safety with the staff. The CNMs will 

randomly check the medication carts four times a month for six months for a target of 

100% and report to the Nursing Performance Improvement (PI) committee and Quality 

and Performance (QP). 

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

Recommendation 3. We recommended that processes be strengthened to ensure that 

auditory privacy is maintained in all intake areas, that managers stress to staff that 

sensitive patient information should not be discussed in public areas, and that 

compliance be monitored. 

Concur 

Target date for completion: February 2, 2015 

Facility response: 

1. Construction for redesigning the Emergency Department is planned and will expand 

the number of rooms. ED staff members were educated on how to maintain privacy in 

limited spaces including the use of screens when the need for additional space is 

required. This area will be monitored randomly for a minimum of 15 observations for 

two quarters using the ‘secret shopper’ technique. The Associate Chief Nursing Service 

(ACNS) of Integrated Clinical Services will report the results of the observation to the 

Nursing Performance Improvement (PI) committee and Quality and Performance (QP). 

The target is 100%. 

2. We will verify that residents rotating at the VA have completed the HIPPA Privacy 

Rules through Talent Management System (TMS). This will be completed monthly and 

reported to Quality and Performance (QP). In addition, it will also be added to the 

curriculum at the monthly medicine resident’s orientation for added emphasis. 

3. Signage for acknowledging the patient’s privacy will be developed and posted in 

rooms specifically reserved for Medical and Surgical Residents. The Administrative 

Officer (AO) to Medicine Service will submit the requests and report completion to QP. 

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

all designated eye clinic employees receive eye laser safety training with the frequency 

required by local policy and that compliance be monitored. 

Concur 

Target date for completion: February 2, 2015 

Facility response: 

1. Surgical Service and the Medical Staff Coordinator will ensure new users have 

computer and hands-on training prior to being approved to use the Laser. The 

physicians will provide the Medical Staff Coordinator proof of Laser training as part of 

the re-credentialing process every two years. Laser training compliance is monitored by 

the Chief of Surgical Service and reported to the Clinical Exec Committee and QP for a 

target of 100% compliance. 

2. The medical center Laser safety policy will be revised to reflect the training 

requirements. 

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

3. Physicians and OR staff that are involved with Laser procedures will take the training 

this year to establish a known frequency. Computer based training will be assigned on 

a two year cycle. 

4. All OR staff members will take annual hands-on Laser competency training and 

document training in the Talent Management System (TMS). 

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

clinicians document patient/caregiver understanding of discharge instructions and that 

compliance be monitored. 

Concur 

Target date for completion: February 2, 2015 

Facility response: Clinical Nurse Manager (CNM), Associate Chief Nursing Service 

(ACNS) for Medicine Service and QM Coordinator for Medicine Service will revise the 

Outpatient Discharge Handoff Template to include the statement “the patient verbalized 

understanding of discharge instruction “yes or no” and if no why and what is the 

intervention. This is a forced field and must be completed. The medical records will be 

audited for six months for a target of 100% and reported to the Nursing PI committee 

and QP. D= # of medical records; N= # of records with understanding of education 

documented. 

Recommendation 6. 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: February 2, 2015 

Facility response: In 2013, NIH Stroke Scale documentation was requested to be 

completed by the ED providers and was not completed on all patients. The new 

process is the Neurology attending physicians and/or resident are responsible for 

completing the NIH documentation. The Chief of Neurology will monitor compliance 

monthly for a target of 100% and report compliance to the Clinical Executive and Quality 

Leadership Committees. 

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

clinicians screen patients for difficulty swallowing prior to oral intake. 

Concur 

Target date for completion: February 2, 2015 

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

Facility response: Nursing swallow assessment protocol will integrate stroke dysphagia 

screen and follow up. The Stroke team will: 

1. Align stroke swallow screen protocol with medical center policy, Management of 

Patients with Swallowing (Dysphagia) or Feeding Disorders (VHA Directive 2006-032) 

and obtain administrative approval. 

2. Revise and assign CPRS Dysphagia Screening template as required on nursing 

admission for acute and LTC, consistent with new policy. 

3. Develop and implement training program for all applicable nursing staff re: swallow 

screen procedure and follow-up on admission and for other specified indications. 

4. Assign and monitor monthly training completion in TMS over six months and report to 

Quality and Performance and the Stroke Steering Committee. The Stroke Center 

Director (also the Chief of Neurology) will monitor compliance with swallow screen for all 

acute stroke admissions through monthly VISN 11 Data Warehouse report 

(Stroke Steering Committee). The target is 100%. 

Recommendation 8. 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: February 2, 2015 

Facility response: Stroke education has been embedded into the Physician discharge 

note. Physicians will be responsible for checking the stroke education button for every 

stroke patient for review and understanding. When the discharge note is printed, the 

stroke education is included. A random audit of 50% of acute stroke patients will be 

completed monthly by the ACNS for Integrated Clinical Service (ICS) and Medicine 

Service for 6 months. The target is 100%. 

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

employees who are involved in assessing and treating stroke patients receive the 

training required by the facility and that compliance be monitored. 

Concur 

Target date for completion: February 2, 2015 

Facility response: The Stroke Center Director will ensure Integrated Clinical Services 

providers complete required training and document in TMS. Training will be required 

every two years. The Stroke Center Director will monitor compliance quarterly, 

including training for new staff members and, report to the Clinical Executive and 

Quality Leadership Committees. The target is 100%. 

VA OIG Office of Healthcare Inspections 25 
 

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

Recommendation 10. We recommended that processes be strengthened to ensure 

that staff complete and document restorative nursing services according to clinician 

orders and/or residents’ care plans and that compliance be monitored. 

Concur 

Target date for completion: February 2, 2015 

Facility response: The Restorative Coordinator will develop a weekly documentation 

note that addresses restorative orders per clinician orders and/or resident care plan, 

revise audit tool to capture restorative requirements and educate staff on revised weekly 

note. The Restorative Coordinator will document training in Talent Management 

System (TMS). The Community Living Center (CLC), Clinical Nurse Managers (CNMs) 

will monitor and compliance weekly and report compliance monthly to Nursing 

Performance Improvement (PI) committee and Quality and Performance (QP). 

Target – 100% compliance. 

Recommendation 11. We recommended that processes be strengthened to ensure 

that staff modify restorative nursing interventions as needed and document the 

modifications and that compliance be monitored. 

Concur 

Target date for completion: February 2, 2015 

Facility response: The weekly note will include resident progress towards goals or 

consult to Restorative Coordinator if compliance is not met or if modifications to the plan 

need to be addressed. The CLC CNMs will complete a weekly audit of documentation 

in the weekly note and report compliance monthly to Nursing PI committee and QP. 

Target – 100% compliance. 

Recommendation 12. We recommended that processes be strengthened to ensure 

that staff document the reasons for not providing restorative nursing services when 

those services are care planned and that compliance be monitored. 

Concur 

Target date for completion: February 2, 2015 

Facility response: The Restorative Coordinator will reinforce education on 

documentation requirements of daily restorative services. The CNMs will monitor 

documentation weekly and report compliance monthly to Nursing PI committee and QP. 

Target – 100% compliance. 

VA OIG Office of Healthcare Inspections 26 
 

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

Recommendation 13. We recommended that processes be strengthened to ensure 

that hand-off communication occurs between Physical Medicine and Rehabilitation 

Service and the community living center when residents are discharged from therapy to 

ensure that restorative nursing services occur. 

Concur 

Target date for completion: February 2, 2015 

Facility response: The Chief of PM&R and ACNS for Geriatrics will ensure hand-off 

communication occurs between PM&R and CLC when residents are discharged. 

PM&R Chief will review Restorative Template to ensure all restorative programs are 

listed and that staff members use the Restorative Consult as a means of Hand-Off. 

100% of residents discharged from PM&R will have a Restorative Consult. 

Recommendation 14. We recommended that processes be strengthened to ensure 

that employees who perform restorative nursing services receive training on range of 

motion and resident transfers. 

Concur 

Target date for completion: February 2, 2015 

Facility response: The Restorative Coordinator will ensure that all training activities 

provided to staff are addressed in the training module and documented including range 

of motion and resident transfers. The CNMs will monitor training and report compliance 

monthly to Nursing PI committee and QP for six months. Target – 100% staff training. 

Recommendation 15. We recommended that processes be strengthened to ensure 

that staff document residents’ restorative progress weekly and that compliance be 

monitored. 

Concur 

Target date for completion: February 2, 2015 

Facility response: The CLC CNMs will observe for compliance to staff documentation on 

restorative progress during daily GEMBA walks (the process of walking around the work 

area to identify improvement opportunities and wasteful activities). The Restorative 

Coordinator will perform bi-monthly audits of documentation requirements. CNMs will 

monitor compliance and report monthly to Nursing PI committee and QP for six months. 

Target – 100% staff training. 

Recommendation 16. We recommended that processes be strengthened to ensure 

that initial patient safety screenings are conducted and that compliance be monitored. 

Concur 

Target date for completion: February 2, 2015 

VA OIG Office of Healthcare Inspections 27 
 

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

Facility response: Providers will be instructed via email and staff meeting to order MRI 

exams using the MRI Procedure tab which has the pre-screening form attached to the 

order. Radiology will monitor and report compliance to the appropriate Service/Section 

Chiefs. Compliance will be monitored for six months by the Chief Technologist. Results 

of the monitor will be reported by the Chief Technologist at the monthly staff meeting 

and to QP. The target is 100%. 

Recommendation 17. We recommended that processes be strengthened to ensure 

that radiologists and/or Level 2 magnetic resonance imaging personnel document 

resolution in patients’ electronic health records of all identified magnetic resonance 

imaging contraindications prior to the scan and that compliance be monitored. 

Concur 

Target date for completion: February 2, 2015 

Facility response: Revise the second screening form that is completed by the patient on 

the day of the procedure, to include comment/assessment for contraindications to 

MRI’s. Screening form will be scanned into CPRS and linked to the MRI order. 

Radiology note will be placed in CPRS to document contraindications. Chief 

Technologist and or designated radiologist will monitor compliance for six months and 

report results at the monthly staff meeting and to QP. The target is 100%. 

Recommendation 18. We recommended that processes be strengthened to ensure 

that all designated Level 1 ancillary staff and Level 2 magnetic resonance imaging 

personnel receive annual level-specific magnetic resonance imaging safety training and 

that compliance be monitored. 

Concur 

Target date for completion: February 2, 2015 

Facility response: 

1. Chief, Education and Information and the Chief Technologist identified Level 2 MRI 

safety training; however, the request was blocked due to access being denied by the 

website. We have submitted Form VA0882 on 8-12-14 to the VA Network Security 

Operations Center (VA-NSOC) to unblock this course. We are currently reviewing other 

suitable training that can be assigned to the appropriate staff if the first choice is denied. 

The Chief Technologist will assign annual training to the Radiology staff, monitor 

compliance in TMS and report results at the monthly staff meeting and to QP. The 

target is 100%. 

2. The ACNS for Integrated Clinical Services will assign training to the appropriate 

nursing staff for Levels 1 and 2 training (Level 2 training for nursing staff assigned to 

Radiology), monitor in TMS for annual training and report compliance in Nursing PI 

committee and to QP. 

VA OIG Office of Healthcare Inspections 28 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Recommendation 19. We recommended that processes be strengthened to ensure 

that two-way communication devices are regularly tested and that compliance be 

monitored. 

Concur 

Target date for completion: February 2, 2015 

Facility response: On 7-22-14, the Chief Technologist updated the daily QA log record 

to include documentation of daily testing of the communication device on the GE 

scanner. The QA log record will be initiated for the Phillips scanner. All MRI 

technologists were notified to document testing. Compliance monitoring will be done by 

the Chief Technologist, reported at the monthly staff meeting and to QP. The target 

is 100%. 

VA OIG Office of Healthcare Inspections 29 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Appendix E 

OIG Contact and Staff Acknowledgments 

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

at (202) 461-4720. 

Onsite 

Contributors 

Other 

Contributors 

Wachita Haywood, RN, Team Leader 

Debra Boyd-Seale, RN, PhD 

Alicia Castillo-Flores, MBA, MPH 

Sheila Cooley, GNP, MSN 

Judy Montano, MS 

Gavin McClaren, Resident Agent in Charge, Office of 

Investigations 

Judy Brown 

Elizabeth Bullock 

Shirley Carlile, BA 

Paula Chapman, CTRS 

Lin Clegg, PhD 

Marnette Dhooghe, MS 

Jeff Joppie, BS 

Nathan McClafferty, MS 

Patrick Smith, M. Stat 

Laura Spottiswood, RN, MPH 

Julie Watrous, RN, MS 

Jarvis Yu, MS 

VA OIG Office of Healthcare Inspections 30 
CAP Review of the John D. Dingell VA Medical Center, Detroit, MI 

Appendix F 

Report Distribution 

VA Distribution 

Office of the Secretary 

VHA 

Assistant Secretaries 

General Counsel 

Director, Veterans In Partnership (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 

House of Representatives: Kerry Bentivolio; John Conyers, Jr.; John Dingell; 

Sander Levin; Candice Miller; Gary Peters; Mike Rogers 

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

VA OIG Office of Healthcare Inspections 31 
 

 

 

 

 

 

 

 

 

 

 

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

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 1142.01, Criteria and Standards for VA Community Living Centers (CLC), August 13, 2008. 

 VHA Handbook 1142.03, Requirements for Use of the Resident Assessment Instrument (RAI) Minimum Data Set 

(MDS), January 4, 2013. 

 Centers for Medicare and Medicaid Services, Long-Term Care Facility Resident Assessment Instrument User’s 

Manual, Version 3.0, May 2013. 

 VHA Manual M-2, Part VIII, Chapter 1, Physical Medicine and Rehabilitation Service, October 7, 1992. 

 Various requirements of The Joint Commission. 

VA OIG Office of Healthcare Inspections 32 
 

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

g

 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 33