Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 08-02600-100

Combined Assessment Program 

Review of the 

William S. Middleton 

Memorial Veterans Hospital 

Madison, Wisconsin 

March 24, 2009

Washington, DC 20420 
Why We Did This Review 

Combined Assessment Program (CAP) reviews are part of the Office of Inspector 

General's (OIG's) efforts to ensure that high quality health care is provided to our 

Nation's veterans. CAP reviews combine the knowledge and skills of the OIG's Offices 

of Healthcare Inspections and Investigations to provide collaborative assessments of 

VA medical facilities on a cyclical basis. The purposes of CAP reviews are to: 

• Evaluate how well VA facilities are accomplishing their missions of providing veterans 

convenient access to high quality medical services. 

• Provide fraud and integrity awareness training to increase employee understanding of 

the potential for program fraud and the requirement to refer suspected criminal activity 

to the OIG. 

In addition to this typical coverage, CAP reviews may examine issues or allegations 

referred by VA employees, patients, Members of Congress, or others. 

To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

Table of Contents 

Page 

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

Introduction ................................................................................................................ 1

Profile...................................................................................................................... 1

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

Organizational Strengths........................................................................................... 3

Results ........................................................................................................................ 4

Review Activities With Recommendations .............................................................. 4

Quality Management ......................................................................................... 4

Environment of Care.......................................................................................... 5

Coordination of Care ......................................................................................... 7

Emergency/Urgent Care Operations ................................................................. 8

Pharmacy Operations........................................................................................ 9

Review Activities Without Recommendations ......................................................... 11

Staffing .............................................................................................................. 11

Medication Management ................................................................................... 12

Survey of Healthcare Experiences of Patients .................................................. 12

Appendixes

A. Acting VISN Director Comments ....................................................................... 15

B. Hospital Director Comments.............................................................................. 16

C. OIG Contact and Staff Acknowledgments ......................................................... 21

D. Report Distribution............................................................................................. 22

VA Office of Inspector General 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

Executive Summary 

Introduction During the week of December 1–5, 2008, the OIG conducted 

a Combined Assessment Program (CAP) review of the 

William S. Middleton Memorial Veterans Hospital (the 

hospital), Madison, WI. The purpose of the review was to 

evaluate selected operations, focusing on patient care 

administration and quality management (QM). During the 

review, we also provided fraud and integrity awareness 

training to 121 employees. The hospital is part of Veterans 

Integrated Service Network (VISN) 12. 

Results of the 

Review 

The CAP review covered eight operational activities. We 

identified the following organizational strengths and reported 

accomplishments: 

• Patient-centered shift handoff improved care. 

• Resident training resulted in improvements. 

We made recommendations in five of the activities reviewed. 

For these activities, the hospital needed to: 

• Ensure that the clinical privileges granted to contractors do 

not extend beyond the contract period. 

• Correct identified safety deficiencies. 

• Correct identified infection control (IC) deficiencies. 

• Complete patient care equipment preventive maintenance 

(PM) at the required intervals. 

• Ensure that consultation requests are acted on within the 

hospital’s or service’s defined timeframe. 

• Ensure that discharge documentation accurately reflects 

active outpatient medications. 

• Ensure that clinicians document inter-facility transfers in 

accordance with Veterans Health Administration (VHA) 

policy. 

• Complete monthly inspections for all areas where 

controlled substances (CS) are stored. 

• Correct deficiencies identified in the annual pharmacy 

security assessments. 

VA Office of Inspector General i
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

• Ensure more frequent housekeeping service in the 

inpatient pharmacy and repair ceiling leaks in the 

outpatient pharmacy. 

The hospital complied with selected standards in the 

following three activities: 

• Staffing. 

• Medication Management. 

• Survey of Healthcare Experiences of Patients (SHEP). 

This report was prepared under the direction of 

Verena Briley-Hudson, Director, Chicago Office of 

Healthcare Inspections. 

Comments The Acting VISN and Hospital Directors concurred with the 

findings and recommendations and submitted acceptable 

improvement plans. (See Appendixes A and B, 

pages 15–20, for the full text of the Directors’ comments). 

We will follow up on the planned actions until they are 

completed. 

 (original signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General ii
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

Introduction 

Profile Organization. The hospital is an acute care facility located 

in Madison, WI, that provides a broad range of inpatient and 

outpatient health care services. Outpatient care is also 

provided at five community based outpatient clinics in 

Baraboo, Beaver Dam, and Janesville, WI, and in Rockford 

and Freeport, IL. The hospital is part of VISN 12 and has a 

primary service area that includes approximately 

130,000 veterans throughout 15 counties in Wisconsin and 

5 counties in Illinois. Also, the hospital is the specialty care 

referral center for an additional 57,000 veterans in the 

Tomah VA Medical Center’s primary service area. 

Programs. The hospital provides tertiary medical, surgical, 

neurological, and psychiatric care services. It has 87 beds. 

Affiliations and Research. The hospital is affiliated with the 

University of Wisconsin’s School of Medicine and Public 

Health and provides training for 101 residents. It also 

provides training for other disciplines, including nursing, 

physical and occupational therapy, pharmacy, social work, 

dietetics, and other allied health professions. In fiscal year 

(FY) 2008, the hospital research program had 23 VA-funded 

primary investigators and 10 new or renewed projects. The 

budget was $3.8 million. Important areas of research 

included geriatrics, hypertension, infectious diseases, 

swallowing disorders, diabetes, prostate cancer, and 

pulmonary diseases. 

Resources. In FY 2008, medical care expenditures totaled 

$218 million. FY 2008 staffing was 1,148 full-time employee 

equivalents (FTE), including 143 physician and 301 nursing 

FTE. 

Workload. In FY 2008, the hospital treated 30,035 unique 

patients and provided 25,002 inpatient days. The inpatient 

care workload totaled 3,970 discharges, and the average 

daily census was 65.4. Outpatient workload totaled 

267,464 visits. 

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: 

VA Office of Inspector General 1 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

• Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care administration 

and QM.

• Provide fraud and integrity awareness training to increase 

employee understanding of the potential for program 

fraud and the requirement to refer suspected criminal 

activity to the OIG.

Scope. We reviewed selected clinical and administrative 

activities to evaluate the effectiveness of patient care 

administration and QM. Patient care administration is the 

process of planning and delivering patient care. QM is the 

process of monitoring the quality of care to identify and 

correct harmful and potentially harmful practices and 

conditions. 

In performing the review, we inspected work areas; 

interviewed managers and employees; and reviewed clinical 

and administrative records. The review covered the 

following eight activities: 

• Coordination of Care.

• Emergency/Urgent Care (E/UC) Operations.

• Environment of Care (EOC).

• Medication Management.

• Pharmacy Operations.

• QM.

• SHEP.

• Staffing.

The review covered hospital operations for FY 2008 and 

FY 2009 through November 28, 2008, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. We followed up on select recommendations from 

our prior CAP review of the hospital (Combined Assessment 

Program Review of the William S. Middleton Memorial 

Veterans Hospital, Madison, Wisconsin, Report 

No. 05-01383-215, September 30, 2005). The hospital had 

corrected all findings related to health care from our prior 

CAP review. 

We also followed up on recommendations from a prior OIG 

inspection (Assessment of Legionnaire’s Disease Risk in 

Veterans Health Administration Inpatient Facilities, Report 

VA Office of Inspector General 2 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

No. 07-00029-151, June 20, 2007). The inspection surveyed 

inpatient facilities, including the hospital, for Legionnaire’s 

disease (LD) prevention strategies. We found that the 

hospital has a written plan that addresses the prevention of 

LD and that the hospital is consistently performing monthly 

LD risk assessments. We consider the hospital to be in 

compliance with the recommendations. 

During this review, we also presented fraud and integrity 

awareness briefings for 121 employees. These briefings 

covered procedures for reporting suspected criminal activity 

to the OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. Activities in the “Review Activities Without 

Recommendations” section have no reportable findings.

Organizational Strengths 

Patient-Centered 

Shift Handoff 

Improved Care

A need for improved communication on medical and surgical 

units was identified. Data guided the development of a new 

patient handoff process that highlights nursing autonomy and 

commitment to patient-driven care. The process takes 

patient satisfaction into consideration and improves patient 

safety. It also makes nurses accountable for their 

professional practice. This innovation was named 1 of the 

10 “best of the best” national entries by VHA’s National Chief 

Nursing Officer, who recognized the team for their 

accomplishments in October 2008. 

Resident Training 

Resulted in 

Improvements 

The hospital developed a new training experience in quality 

improvement for third-year residents. The goal of the month 

long rotation is for residents to gain an appreciation for how 

problems are identified and how change is effected. Since 

the inception of the program, more than 55 percent of the 

residents’ proposals have been implemented, resulting in 

improvements in medical error reporting, implementation of 

cardiology performance measures, and numerous safety 

initiatives. 

VA Office of Inspector General 3 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

VA Office of Inspector General 4 

Results 

Review Activities With Recommendations 

Quality 

Management 

The purpose of this review was to evaluate whether the 

hospital had a comprehensive and effective QM program 

designed to monitor patient care activities and coordinate 

improvement efforts and whether senior managers actively 

supported the program’s activities. We interviewed the 

hospital’s Director, Associate Director for Patient Care 

Services, Chief of Staff, and Organizational Improvement 

Manager, and we interviewed other key staff. We evaluated 

policies, performance improvement (PI) data, and other 

relevant documents. 

The QM program was generally effective in providing 

oversight of the hospital’s quality of care, and senior 

managers supported the program through evaluation of PI 

initiatives and through allocation of resources to the program. 

Appropriate review structures were in place for 13 of the 

14 program activities reviewed. We identified one area that 

needed improvement. 

Credentialing and Privileging. VHA policy1

 requires that 

clinical privileges be granted for a period not to exceed 

2 years and that privileges granted to contractors do not 

extend beyond the contract period. We reviewed the 

credentialing and privileging folders and corresponding 

contracts of seven contractors who had been initially 

privileged or reprivileged during the past 12 months. We 

found that six contractors had been granted clinical privileges 

that extended beyond the contract period. 

Recommendation 1 We recommended that the Acting VISN Director ensure that 

the Hospital Director requires that clinical privileges granted 

to contractors do not extend beyond the contract period. 

The Acting VISN and Hospital Directors concurred with the 

finding and recommendation. The medical staff privilege 

form for each provider has been changed to clearly indicate 

the type of appointment each holds. For contract staff, the 

privilege form will indicate the specified timeframe for the 

respective contract. The improvement plan is acceptable, 

 

1

 VHA Handbook 1100.19, Credentialing and Privileging, October 2, 2007. 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

and we will follow up on the completion of the planned 

actions. 

Environment of 

Care 

The purpose of this review was to determine whether the 

hospital complied with selected IC standards and maintained 

a safe and clean patient care environment. VHA facilities are 

required to establish a comprehensive EOC program that 

fully meets VHA, Occupational Safety and Health 

Administration, and Joint Commission (JC) standards. 

We inspected the inpatient medical/surgical units (4B, 7B), 

the locked acute psychiatry unit (2B), the coronary intensive 

care unit (CCU), the surgical intensive care unit (SICU), the 

operating room, the post-anesthesia care unit, the speech 

clinic, the audiology clinic, the ear, nose, and throat (ENT) 

clinic, primary care clinic D, and several common areas. 

We evaluated the IC program to determine compliance with 

VHA directives. IC staff appropriately collected, trended, and 

analyzed data related to infections, and they involved 

clinicians in improvement initiatives to reduce infection risks 

for patients and staff. IC staff also provided in-service 

education as new health concerns were identified. 

The hospital was generally clean and effectively maintained. 

EOC recommendations from our prior CAP review had been 

corrected. Nurse managers and unit staff expressed 

satisfaction with the responsiveness of the housekeeping 

staff on their units. However, we identified the following 

areas that needed improvement. 

Safety. Medication and nourishment refrigerators must be 

monitored daily to ensure that contents are safe. We found 

expired medications in refrigerators on medical/surgical unit 

7B, in the E/UC area, and in primary care clinic D. Expired 

nourishments were found in refrigerators on the CCU and on 

the SICU. 

Oxygen tanks must be stored so that staff may quickly 

identify which are full and which are empty. The units we 

inspected did not have a clear separation between full and 

empty tanks. 

Sharp items must be secured from public access. In the 

ENT clinic, there were sharp items in an unlocked soiled 

utility room. 

VA Office of Inspector General 5 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

Infection Control. Patient care equipment and furniture need 

to be regularly inspected, and items with compromised 

surfaces need to be repaired or removed from service. We 

identified a reclining chair with compromised surfaces on 

medical/surgical unit 4B. We also identified one chair in 

primary care clinic D and six chairs in the outpatient 

pharmacy waiting room with compromised surfaces. 

Managers reported that new chairs for primary care clinic D 

and the outpatient pharmacy had been ordered. 

Storage areas need to be maintained so that clean and dirty 

items are separated. We identified storage rooms that 

contained a mixture of items, for example, clean linens and 

patient care equipment stored with soiled equipment, 

patients’ personal clothing, and soiled linen containers. 

Preventive Maintenance. We evaluated whether the hospital 

had effective processes in place to ensure that patient care 

equipment items are properly cleaned and maintained. We 

selected 26 equipment items and reviewed corresponding 

PM records from Biomedical Engineering. PM records 

showed that 23 (88 percent) equipment items had been 

cleaned and maintained as required and that they had 

received PM at the recommended intervals. Three 

equipment items had not received the required PM. 

Recommendation 2 We recommended that the Acting VISN Director ensure that 

the Hospital Director requires that identified safety 

deficiencies be corrected. 

The Acting VISN and Hospital Directors concurred with the 

findings and recommendation. The hospital developed 

appropriate plans to address the safety deficiencies identified 

during the inspection. Refrigerators will be monitored, full 

and empty oxygen tanks will be physically separated, and 

spot checks for sharp items will be conducted. The 

improvement plans are acceptable, and we will follow up on 

the completion of the planned actions. 

Recommendation 3 We recommended that the Acting VISN Director ensure that 

the Hospital Director requires that identified IC deficiencies 

be corrected. 

The Acting VISN and Hospital Directors concurred with the 

findings and recommendation. The hospital developed 

appropriate plans to address the IC deficiencies identified 

during the inspection. Replacement chairs will be delivered, 

VA Office of Inspector General 6 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

VA Office of Inspector General 7 

and staff have been re-educated regarding the separation of 

clean and dirty items. The improvement plans are 

acceptable, and we will follow up on the completion of the 

planned actions. 

Recommendation 4 We recommended that the Acting VISN Director ensure that 

the Hospital Director requires that patient care equipment 

receives PM at the required intervals. 

The Acting VISN and Hospital Directors concurred with the 

finding and recommendation. The hospital found that PM 

had been completed on the three identified equipment items; 

however, the electronic PM logs had not been updated. The 

logs were updated on December 17, 2008. The corrective 

action is acceptable, and we consider this recommendation 

closed. 

Coordination of 

Care 

The purpose of this review was to evaluate whether 

consultations, intra-facility transfers, and discharges were 

appropriately coordinated and met VHA and JC standards. 

Coordinated consultations, transfers, and discharges are 

essential to an integrated, ongoing care process resulting in 

optimal patient outcomes. We identified two areas that 

needed improvement. 

Consultations. Hospital and service-specific policies define 

timeframes for responses to consultation requests. We 

reviewed the medical records of nine inpatients who had 

routine consultations ordered and internally completed. We 

noted that for one patient, the service consulted documented 

their response 6 days after the provider’s request, which was 

outside the defined timeframe. 

Discharges. VHA policy2

 addresses information to be 

documented in the medical record when a patient is 

discharged. We reviewed the medical records of nine 

inpatients who were discharged from the hospital. There 

was one instance in which the provider’s discharge note 

included outpatient medications that were listed twice—once 

as “active” and once as “pending.” Since this information is 

given to the patient, there is potential for errors in medication 

dosing. Also, in three medical records, we identified 

discrepancies between active outpatient medications listed in 

 

2

 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

VA Office of Inspector General 8 

the provider’s discharge summary, those listed in the 

discharge orders, and/or those listed in the pharmacist’s 

patient education note. 

Recommendation 5 We recommended that the Acting VISN Director ensure that 

the Hospital Director requires that consultation requests are 

acted on within the hospital’s or service’s defined timeframe. 

The Acting VISN and Hospital Directors concurred with the 

finding and recommendation. The provider for the one 

delinquent consult has been re-educated regarding policy 

timeframes. The corrective action is acceptable, and we 

consider this recommendation closed. 

Recommendation 6 We recommended that the Acting VISN Director ensure that 

the Hospital Director requires that discharge documentation 

accurately reflects active outpatient medications. 

The Acting VISN and Hospital Directors concurred with the 

findings and recommendation. Discharge medications will 

be finalized by the medical team prior to the pharmacy 

discharge appointment. A pharmacist will prepare the final 

medication document and educate the patient. The 

discharge summary and the outpatient pharmacy list will 

reflect the medications in the pharmacy discharge note. The 

improvement plans are acceptable, and we will follow up on 

the completion of the planned actions. 

Emergency/Urgent 

Care Operations 

The purpose of this review was to evaluate whether the 

hospital’s E/UC operations complied with VHA guidelines 

related to hours of operation, clinical capability, staffing 

adequacy, and staff competency. In addition, we inspected 

the hospital’s E/UC environment for cleanliness and safety. 

The hospital’s E/UC facility is open 24 hours per day, 7 days 

per week, as required. It is located within the main hospital 

building, and the emergency services provided are within the 

hospital’s capability. In addition, there is an appropriate 

policy for managing patients whose care may exceed the 

hospital’s capability. We identified one area that needed 

improvement. 

Inter-Facility Transfer Documentation. VHA policy3

 requires 

the use of specific forms for the documentation of 

inter-facility transfers. We reviewed the medical records of 

 

3

 VHA Directive 2007-015, Inter-Facility Transfer Policy, May 7, 2007. 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

three patients who were initially treated in the E/UC facility 

and then transferred to other facilities. The hospital was 

unable to locate the required documentation, so we were 

unable to determine whether the forms were completed. 

Recommendation 7 We recommended that the Acting VISN Director ensure that 

the Hospital Director requires that clinicians document 

inter-facility transfers in accordance with VHA policy. 

The Acting VISN and Hospital Directors concurred with the 

finding and recommendation. The hospital has developed 

and implemented templates for inter-facility transfers that are 

congruent with VHA policy. The improvement plan is 

acceptable, and we will follow up on the completion of the 

planned actions. 

Pharmacy 

Operations 

The purpose of this review was to evaluate whether the 

hospital had adequate controls to ensure the security and 

proper management of CS and the pharmacies’ internal 

physical environments. We also assessed whether 

processes were in place to monitor polypharmacy (patients 

prescribed multiple medications), especially in vulnerable 

populations. 

We reviewed VHA regulations governing pharmacy and CS 

security, and we assessed whether the hospital’s policies 

and practices were consistent with VHA regulations. We 

inspected the inpatient and outpatient pharmacies, the clean 

room, and the vaults for security, EOC, and IC issues. 

Additionally, we interviewed the CS Coordinator and 

pharmacy managers. 

Pharmacological regimens involving multiple medications are 

often necessary to prevent and maintain disease states; 

however, excessive use of medications can result in adverse 

reactions and increased risks of complications. 

Polypharmacy is more complex than just the number of 

drugs that patients are prescribed. The clinical criteria to 

identify polypharmacy are the use of: (a) medications that 

have no apparent indication, (b) therapeutic equivalents to 

treat the same illness, (c) medications that interact with other 

prescribed drugs, (d) inappropriate medication dosages, and 

(e) medications to treat adverse drug reactions. Elderly and 

mental health patients are among the most vulnerable 

populations for polypharmacy. 

VA Office of Inspector General 9 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

VA Office of Inspector General 10 

Managers had developed effective processes to ensure that 

clinical pharmacists identified patients who were prescribed 

multiple medications, reviewed their medication regimens to 

avoid polypharmacy, and advised providers as appropriate. 

Policies and procedures were in place to ensure the security 

of the pharmacies and CS. The CS Coordinator and CS 

inspectors were appointed in writing by the hospital’s 

Director and received the required training to perform their 

duties. The pharmacies’ internal environments were 

generally clean and well maintained. We identified three 

areas that needed improvement. 

Controlled Substances Inspections. VHA policy4

 requires 

monthly, random inspections of all areas where CS are 

stored. Through interviews and reviews of inspection 

documents, we learned that the August 2008 inspection of 

the infusion clinic was missed. 

Pharmacy Security. VA policy5

 requires an annual security 

assessment of all pharmacy areas. We reviewed the 2006, 

2007, and 2008 annual security assessment reports and 

found that discrepancies identified during the 

2006 inspection had not been fully resolved by the date of 

the 2008 inspection. 

Environment of Care. During our tour of the inpatient 

pharmacy, we noted a significant amount of debris on the 

floor. This area was under construction. Further 

housekeeping services were needed to ensure that the area 

remained clean. During our tour of the outpatient pharmacy, 

we noted two stained ceiling tiles adjacent to an exterior wall 

and window. Employees stated that there were leaks, 

especially during heavy rains. Although some repairs had 

been initiated, the problem had not been resolved. 

Recommendation 8 We recommended that the Acting VISN Director ensure that 

the Hospital Director requires that monthly inspections are 

completed for all areas where CS are stored. 

The Acting VISN and Hospital Directors concurred with the 

finding and recommendation. Policies are in place for CS 

inspections to be completed on a monthly basis for each 

area of the hospital that stores CS. Verification of all monthly 

 

4

 VHA Handbook 1108.2, Inspection of Controlled Substances, August 29, 2003. 5

 VA Handbook 0730/1, Security and Law Enforcement, August 20, 2004. 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

inspections will be completed at the CS inspectors meetings. 

The improvement plan is acceptable, and we will follow up 

on the completion of the planned actions. 

Recommendation 9 We recommended that the Acting VISN Director ensure that 

the Hospital Director requires that deficiencies identified in 

the annual pharmacy security assessments be corrected. 

The Acting VISN and Hospital Directors concurred with the 

finding and recommendation. The “Upgrade Physical 

Security Project” currently in progress in the inpatient and 

outpatient pharmacy areas will resolve the deficiencies 

identified in the annual pharmacy security assessments. The 

improvement plan is acceptable, and we will follow up on the 

completion of the planned actions. 

Recommendation 10 We recommended that the Acting VISN Director ensure that 

the Hospital Director requires more frequent housekeeping 

service in the inpatient pharmacy and repair of ceiling leaks 

in the outpatient pharmacy. 

The Acting VISN and Hospital Directors concurred with the 

findings and recommendation. Engineering Service is 

reinforcing the requirement for contractors to clean 

construction areas daily, and additional housekeeping 

support is being provided. The ceiling leak in the outpatient 

pharmacy has been fixed. The improvement plans are 

acceptable, and we will follow up on the completion of the 

planned actions. 

Review Activities Without Recommendations 

Staffing The purpose of this review was to evaluate whether the 

hospital had developed comprehensive nurse staffing 

guidelines and to determine whether the nurse staffing 

provided corresponded to the hospital’s methodology. 

Identifying and providing the correct number and/or mix of 

nurses is essential to the delivery of high quality patient care. 

The hospital’s staffing methodology is based upon a mix of 

licensed and non-licensed personnel varied by night, day, 

and evening shifts. We reviewed staffing for four inpatient 

units for three randomly selected dates. The dates included 

a weekday, a weekend day, and a holiday. We reviewed 

nurse staffing documents and interviewed managers for 

select units, including the locked acute psychiatry unit, a 

medical/surgical unit, the CCU, and the SICU. We found the 

VA Office of Inspector General 11 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

nurse staffing methodology to be appropriate. We made no 

recommendations. 

Medication 

Management 

The purpose of this review was to evaluate whether the 

hospital had adequate medication management practices. A 

safe medication management system includes medication 

ordering, administering, and monitoring. 

We reviewed medication management processes on the 

locked acute psychiatry unit, the CCU, and two 

medical/surgical units. We found appropriate use of patient 

armbands to correctly identify patients prior to medication 

administration. We made no recommendations. 

Survey of 

Healthcare 

Experiences of 

Patients 

The purpose of this review was to assess the extent that the 

hospital uses quarterly SHEP results to improve patient care, 

treatment, and services. The Performance Analysis Center 

for Excellence of the Office of Quality and Performance 

within VHA is the analytical, methodological, and reporting 

staff for SHEP. VHA set performance measure results for 

patients reporting overall satisfaction of “very good” or 

“excellent” at 76 percent for inpatients and 77 percent for 

outpatients. 

Figures 1 and 2 on the next page show the hospital’s SHEP 

performance measure results for inpatients and outpatients, 

respectively. 

VA Office of Inspector General 12 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

60

65

70

75

80

85

90

95

100

Qtr 4 (FY 06) Qtr 1 (FY 07) Qtr 2 (FY 07) Qtr 3 (FY 07) Qtr 4 (FY 07) Qtr 1 (FY 08) Qtr 2 (FY 08) Qtr 3 (FY 08)

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

Facility

VISN

National

WILLIAM S. MIDDLETON MEMORIAL VETERANS HOSPITAL

INPATIENT OVERALL QUALITY

BY QUARTER

Meets 

Target

Figure 1:

60

65

70

75

80

85

90

95

100

Qtr 4 (FY 06) Qtr 1 (FY 07) Qtr 2 (FY 07) Qtr 3 (FY 07) Qtr 4 (FY 07) Qtr 1 (FY 08) Qtr 2 (FY 08) Qtr 3 (FY 08)

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

Facility

VISN

National

WILLIAM S. MIDDLETON MEMORIAL VETERANS HOSPITAL

OUTPATIENT OVERALL QUALITY

BY QUARTER

Figure 2:

Meets 

Target

VA Office of Inspector General 13 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

We reviewed survey results for quarter 4 of FY 2006 through 

quarter 3 of FY 2008. The hospital’s inpatient and outpatient 

results exceeded the target in all 8 quarters reviewed. 

Managers had analyzed survey results, identified 

opportunities for improvement, initiated an action plan, and 

evaluated the plan for effectiveness. We made no 

recommendations. 

VA Office of Inspector General 14 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

Appendix A 

Acting VISN Director Comments 

VA Office of Inspector General 15 

Department of 

Veterans Affairs Memorandum 

Date: January 23, 2009 

From: Acting Network Director, VA Great Lakes Health Care 

System (10N12) 

Subject: Combined Assessment Program Review of the 

William S. Middleton Memorial Veterans Hospital, 

Madison, Wisconsin 

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

Director, Management Review Service (10B5) 

1. I concur with the Office of Healthcare Inspections recommendations as 

well as the corrective action plans developed by the Madison VA 

Hospital. 

2. Thank you for the opportunity to review the findings enclosed in this 

report. 

Renee Oshinski 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

Appendix B 

Hospital Director Comments 

VA Office of Inspector General 16 

Department of 

Veterans Affairs Memorandum 

Date: January 21, 2009 

From: Director, William S. Middleton Memorial Veterans Hospital 

(607/00) 

Subject: Combined Assessment Program Review of the 

William S. Middleton Memorial Veterans Hospital, 

Madison, Wisconsin 

To: Acting Director, VA Great Lakes Health Care System 

(10N12) 

Director, Chicago Office of Healthcare Inspections (54CH) 

1. Thank you for the opportunity to review the draft report on the 

Combined Assessment Program Review of the VAMC Madison (607). 

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

Corrective action plans have been established with planned completion 

dates, as detailed in the attached report. 

(original signed by:) 

DEBORAH A. THOMPSON 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

Comments to Office of Inspector General’s Report 

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

recommendations in the Office of Inspector General Report: 

OIG Recommendations

Recommendation 1. We recommended that the Acting VISN Director 

ensure that the Hospital Director requires that clinical privileges granted to 

contractors do not extend beyond the contract period. 

Concur Completed 

The Medical Staff privilege form for each provider has been changed to 

clearly indicate what type of Medical Staff appointment they hold. For 

individual contract staff, the privilege form will indicate the specified 

timeframe for the respective contract. The process change of having 

dates of clinical privileges coincide with active contract dates noted on the 

privileging form began January 12, 2009. 

Recommendation 2. We recommended that the Acting VISN Director 

ensure that the Hospital Director requires that identified safety deficiencies 

be corrected. 

Concur Target Date of Completion: February 28, 2009 

Food and Nutrition services do a daily sweep of nourishments in the 

patient care unit refrigerators. F&NS supervisor will reinforce the need to 

remove expired items. Refrigerator surveillance rounds will be 

implemented in CCU and SICU, with reports sent to F&NS supervisor for 

the next 3 months to ensure the process is working. 

Although a pharmacy process is already in place to identify expired 

medications, this review indentified expired medication on 7B, E/UC, and 

outpatient Clinic D. An additional process will be implemented by 

February 1, 2009, in these areas for an LPN to double check the 

refrigerators on a daily basis during open clinic hours for 3 months to 

assure the Pharmacy process is working. 

There will be a clear delineation of full and empty oxygen tanks such that 

there will be physical separation of tank storage with signage to indicate 

full and empty tanks. The process change will be completed by 

February 28, 2009. 

VA Office of Inspector General 17 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

A sweep of the ENT clinic was done to ensure there were no sharp items 

left in public places. Staff was educated regarding the importance of 

securing sharps. Spot checks of the ENT clinic will be done on a weekly 

basis for 2 months to ensure that there are no sharps left in public places. 

Recommendation 3. We recommended that the Acting VISN Director 

ensure that the Hospital Director requires that identified IC deficiencies be 

corrected. 

Concur Target Date of Completion: March 31, 2009 

Chairs with compromised seating surfaces identified during survey 

(outpatient pharmacy, clinic D, and 4B inpatient unit) were removed 

January 20, 2009. Replacement chairs for the outpatient clinic areas had 

already been ordered by the facility at the time of the CAP review. These 

chairs are scheduled to be in place by March 31, 2009. To the best of our 

knowledge, there was one storage room, on one unit, that there was a mix 

of clean and dirty items found. Unit staff have been re-educated regarding 

the need to maintain separate storage of clean and dirty items as defined 

in hospital policy 111-13 (Hand Hygiene, Standard Precautions and 

Isolation). 

Recommendation 4. We recommended that the Acting VISN Director 

ensure that the Hospital Director requires that patient care equipment 

receives PM at the required intervals. 

Concur Completed 

The facility has an effective process in place for equipment preventive 

maintenance. The PM’s had been completed on the three pieces of 

equipment and had stickers on the equipment indicating timely 

maintenance. The issue was that the computer entry process to update 

the PM log had not yet been done. This was completed on 

December 17, 2008. 

Recommendation 5. We recommended that the Acting VISN Director 

ensure that the Hospital Director requires that consultation requests are 

acted on within the hospital’s or service’s defined timeframe. 

Concur Completed 

Appropriate policies are in place to define timeframes for consult 

completion for inpatients. The provider for the one delinquent consult has 

been re-educated regarding the policy timeframes. 

VA Office of Inspector General 18 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

Recommendation 6. We recommended that the Acting VISN Director 

ensure that the Hospital Director requires that discharge documentation 

accurately reflects active outpatient medications. 

Concur Target Date of Completion: March 30, 2009 

The discharge medications must be finalized by the medical team prior to 

the pharmacy discharge appointment. The pharmacist will prepare the 

final medication use document and educate the patient. The discharge 

summary and the outpatient pharmacy list will reflect the medications in 

the pharmacy discharge note. This process change will be implemented 

March 30, 2009. Monitoring will be done for 3 months post 

implementation to ensure this process change is working. 

Recommendation 7. We recommended that the Acting VISN Director 

ensure that the Hospital Director requires that clinicians document 

inter-facility transfers in accordance with VHA policy. 

Concur Completed 

Templates for inter-facility transfers that meet VHA policy were developed 

and implemented in late November 2008, just days before the CAP 

review. The two inter-facility transfers that were completed after the 

implementation were in compliance with facility and VHA policy. We will 

continue to use the new process. 

Recommendation 8. We recommended that the Acting VISN Director 

ensure that the Hospital Director requires that monthly inspections are 

completed for all areas where CS are stored. 

Concur Completed 

Policies are in place for controlled substance inspections to be completed 

on a monthly basis, with each area of the hospital that stores controlled 

substances to be inspected monthly. Infusion clinic was inadvertently 

missed during the month of August given this was the first time ever that 

the infusion clinic was on the schedule. Previous to this date infusion 

clinic did not store narcotics. This appears to be an aberration in the fact 

that for the past 2 years there had not been a missing inspection. 

Verification of all monthly inspections is completed at the Controlled 

Substance Inspectors meeting. 

Recommendation 9. We recommended that the Acting VISN Director 

ensure that the Hospital Director requires that deficiencies identified in the 

annual pharmacy security assessments be corrected. 

Concur Target Date of Completion: April 25, 2009 

VA Office of Inspector General 19 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

VA Office of Inspector General 20 

The contracted “Upgrade Physical Security Project” currently in progress 

in the inpatient and outpatient pharmacy areas will be completed on 

April 25, 2009. The completion of this project will resolve the identified 

deficiencies from the annual pharmacy security assessments. 

Recommendation 10. We recommended that the Acting VISN Director 

ensure that the Hospital Director requires more frequent housekeeping 

service in the inpatient pharmacy and repair of ceiling leaks in the 

outpatient pharmacy. 

Concur Target Date of Completion: April 25, 2009 

During construction, contractors are responsible for cleaning their 

construction sites on a daily basis as identified in their pre-construction 

risk assessment. Engineering Service is now reinforcing this requirement 

at the regular construction meetings. In addition, the housekeeping staff 

assigned to inpatient pharmacy is assisting by providing additional 

housekeeping support. 

The problem causing the ceiling leak in the outpatient pharmacy has been 

corrected. 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

Appendix C 

VA Office of Inspector General 21 

OIG Contact and Staff Acknowledgments 

Contact Verena Briley-Hudson, MN, RN, Director 

Chicago Office of Healthcare Inspections 

(708) 202-5163 

Contributors Lisa Barnes, MSW, Team Leader 

Judy Brown 

Paula Chapman, CTRS 

Jennifer Reed, RN 

Roberta Thompson, MSW 

John Brooks, Office of Investigations 
CAP Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin 

Appendix D 

VA Office of Inspector General 22 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Acting Director, VA Great Lakes Health Care System (10N12) 

Director, William S. Middleton Memorial Veterans Hospital (607/00) 

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: Roland W. Burris, Richard Durbin, Russell D. Feingold, Herb Kohl 

U.S. House of Representatives: Tammy Baldwin, Ron Kind, Donald Manzullo, 

David R. Obey, Thomas Petri, Paul Ryan, F. James Sensenbrenner 

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