Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 08-02414-82

Combined Assessment Program 

Review of the 

Robert J. Dole VA Medical Center 

Wichita, Kansas 

March 3, 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
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

Table of Contents 

Page 

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

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

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

Objectives and Scope ............................................................................................. 2

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

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

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

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

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

Coordination of Care ......................................................................................... 8

Emergency/Urgent Care Operations ................................................................. 9

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

Pharmacy Operations........................................................................................ 11

Review Activities Without Recommendations ......................................................... 13

Staffing .............................................................................................................. 13

Survey of Healthcare Experiences of Patients .................................................. 14

Appendixes

A. VISN Director Comments .................................................................................. 16

B. Medical Center Director Comments................................................................... 17

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

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

VA Office of Inspector General 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

Executive Summary 

Introduction During the week of December 8–12, 2008, the OIG 

conducted a Combined Assessment Program (CAP) review 

of the Robert J. Dole VA Medical Center (the medical 

center), Wichita, KS. 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 145 medical center employees. The medical 

center is part of Veterans Integrated Service Network 

(VISN) 15. 

Results of the 

Review 

The CAP review covered eight operational activities. We 

identified the following organizational strengths and reported 

accomplishments: 

• Duty to report software program. 

• Root cause analysis (RCA) teams. 

We made recommendations in six of the activities reviewed. 

For these activities, the medical center needed to: 

• Ensure that all medical center employees who require 

cardiopulmonary resuscitation (CPR) training and 

automated external defibrillator (AED) training have current 

certification. 

• Modify the local CPR policy to include all employees that 

require training and define the process for tracking current 

training. 

• Maintain medication refrigerator cleanliness in accordance 

with local policy. 

• Modify the local hand hygiene practice policy to include all 

Veterans Health Administration (VHA) requirements and 

provide health care workers with information regarding 

their performance. 

• Ensure that staff are aware of hazardous spill procedures. 

• Monitor and test the electronic elopement system 

according to the manufacturer’s recommendations. 

• Assure the safe use of electrical appliances. 

• Complete intra-facility transfer documentation, as required 

by local policy. 

VA Office of Inspector General i
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

• Complete discharge documentation, as required by Joint 

Commission (JC) standards and local policy. 

• Complete emergency department (ED) inter-facility transfer 

documentation, as required by VHA and local policy. 

• Document the effectiveness of all pain medications within 

the timeframe required by local policy. 

• Ensure that the medical center’s Director initiates and 

signs appointment letters for the alternate Controlled 

Substances Coordinator (CSC) and controlled substances 

inspectors. 

The medical center complied with selected standards in the 

following two activities: 

• Staffing. 

• Survey of Healthcare Experiences of Patients (SHEP). 

This report was prepared under the direction of 

Virginia L. Solana, Director, and James Seitz, Healthcare 

Inspector, Kansas City Office of Healthcare Inspections. 

Comments The VISN and Medical Center Directors agreed with the CAP 

review findings and recommendations and provided 

acceptable improvement plans. (See Appendixes A and B, 

pages 16–20, 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
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

VA Office of Inspector General 1 

Introduction 

Profile Organization. The medical center is located in Wichita, KS, 

and provides a broad range of inpatient and outpatient health 

care services. Outpatient care is also provided at six 

community based outpatient clinics in Parsons, Hutchinson, 

Salina, Hays, Ft. Dodge, and Liberal, KS. The medical 

center is part of VISN 15 and serves a veteran population of 

about 100,500 throughout 59 counties in Kansas. Fourteen 

of these counties are designated as Health Professional 

Shortage Areas (HPSA) for primary care, and 57 of these 

counties are designated as HPSA for mental health. 

Programs. The medical center provides a full range of 

primary, specialty, acute, and extended care services. It has 

41 hospital beds and 40 community living center (CLC) 

beds.1

Affiliations and Research. The medical center is affiliated 

with the University of Kansas’ School of Medicine-Wichita 

and supports 23 medical resident training positions. Also, 

the medical center has developed an affiliation with Wichita 

State University for dental and nursing students. In fiscal 

year (FY) 2008, the medical center research program had 

nine projects and a budget of approximately $6,000. 

Important areas of research include web-based training on 

basic skin cancer triage and pulmonary studies. 

Resources. In FY 2008, medical care expenditures totaled 

$109 million. The FY 2009 medical care budget is

$112 million. FY 2008 staffing was 823 full-time employee 

equivalents (FTE), including 44 physician and 259 nursing 

FTE. 

Workload. In FY 2008, the medical center treated

27,875 unique patients and provided 9,203 inpatient days in 

the hospital and 13,426 inpatient days in the CLC. The 

inpatient care workload totaled 2,165 discharges, and the 

average daily census, including CLC patients, was 62. 

Outpatient workload totaled 515,296 visits. 

 

1

 A CLC (formerly called a nursing home care unit) provides compassionate, person-centered care in a safe and 

homelike environment to eligible veterans who require a nursing home level of care. 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

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 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 Operations.

• Environment of Care (EOC).

• Medication Management.

• Pharmacy Operations.

• QM.

• SHEP.

• Staffing.

The review covered medical center operations for FY 2007, 

FY 2008, and FY 2009 through November 29, 2008, and 

was done in accordance with OIG standard operating 

procedures for CAP reviews. We also followed up on select 

recommendations from our prior CAP review of the medical 

center (Combined Assessment Program Review of the 

Veterans Health Administration Activities at the 

Robert J. Dole VA Medical Center, Wichita, Kansas, Report 

VA Office of Inspector General 2 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

No. 05-03277-121, March 31, 2006). The medical center 

had corrected all findings related to health care from the prior 

CAP review. 

During this review, we also presented fraud and integrity 

awareness briefings for 145 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 

Duty to Report 

Software Program

A team from the medical center developed a reportable 

incident software program that is available to all employees 

by clicking an icon on any medical center computer. The 

purpose of the program is to make it easier for employees to 

report any actual or suspected event, concern, or 

vulnerability that could pose a threat to veterans, staff, or 

stakeholders. Every employee is encouraged to report 

incidents in order to improve systems, processes, and EOC. 

When an employee becomes aware of a potential or actual 

incident, he/she is to submit a computerized report. 

Categories of reports include patient safety; hazards 

(including infection control (IC) concerns); compliance, 

business integrity, and conflict of interest; security and 

privacy; equal employment opportunity and sexual 

harassment; Hatch Act and whistleblower protection; JC; 

coding, billing, and medical documentation; ethics; and time 

and attendance and travel. Although employees may remain 

anonymous, medical center managers have encouraged 

identity disclosure to make follow-up possible. 

Each category has a unique report format. Upon completion, 

reports are forwarded via e-mail to the person responsible 

for that program. Program managers enter data onto 

spreadsheets, and the data is simultaneously displayed 

graphically on a shared drive. This comprehensive software 

program has helped to significantly increase the number of 

reported incidents, resulting in process improvements.

VA Office of Inspector General 3 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

VA Office of Inspector General 4 

Root Cause 

Analysis Teams 

During our prior CAP review, we noted a problem with 

completion of required aggregate and special RCAs. The 

Patient Safety Coordinator initiated a change in the process 

that resulted in the timely completion of all RCAs during the 

last 12 months. 

For each of the major RCA reporting categories, a team 

leader and team members were appointed for a 1-year 

period. Staff from the VA National Center for Patient Safety 

came to the medical center to train the teams. This has 

eliminated the need to search for available staff and train 

them when an RCA is required, thus saving valuable time. If 

the RCA team recommends a process action team (PAT), a 

member of the RCA team serves on the PAT for continuity. 

Since the process was changed, RCAs have provided 

meaningful recommendations that have improved patient 

care and safety. 

Results 

Review Activities With Recommendations 

Quality 

Management 

The purpose of this review was to evaluate whether the 

medical center’s QM program provided comprehensive 

oversight of the quality of care and whether senior managers 

actively supported the program’s activities. We interviewed 

the medical center’s senior management team and QM 

personnel. We evaluated plans, policies, and other relevant 

documents. 

The QM program was generally effective in providing 

oversight of the medical center’s quality of care, and senior 

managers supported the program. Managers had corrected 

findings from the prior CAP review and had made significant 

improvements. Appropriate review structures were in place 

for 13 of the 14 program activities reviewed. We identified 

the following area that needed improvement: 

Cardiopulmonary Resuscitation Training. Police officers did 

not have current training. Medical center police vehicles are 

equipped with an AED, and VHA requires that police officers 

have current CPR and AED training. VA policy2

 requires 

that orientation and mandatory yearly in-service training 

programs for VA police officers include a CPR course 

conducted by a certified instructor. CPR courses include 

 

2

 VA Handbook 0730, Security and Law Enforcement, August 11, 2000. 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

AED training. Although all 11 officers had received initial 

training, 10 (91 percent) had not renewed their training 

certifications when they expired. 

Also, the local policy that defines which medical center 

employees are required to maintain current CPR certification 

does not include police officers. Additionally, the policy does 

not define the process for tracking current training. 

Recommendation 1 We recommended that the VISN Director ensure that the 

Medical Center Director requires that all medical center 

employees who require CPR and AED training have current 

certification. 

The VISN and Medical Center Directors concurred with our 

finding and recommendation. Police Service staff are in the 

process of renewing their certifications. We find this action 

plan appropriate and will follow up on reported 

implementation actions to ensure completion. 

Recommendation 2 We recommended that the VISN Director ensure that the 

Medical Center Director requires that the local CPR policy is 

modified to include all employees who require training and to 

define the process for tracking current training. 

The VISN and Medical Center Directors concurred with our 

findings and recommendation. Education Service is 

reviewing the local CPR policy and is developing a tracking 

system for training. We find this action plan appropriate and 

will follow up on reported implementation actions to ensure 

completion. 

Environment of 

Care 

The purpose of this review was to determine if VHA medical 

centers maintain a safe and clean environment. Medical 

centers are required to provide a comprehensive EOC 

program that fully meets VA National Center for Patient 

Safety, Occupational Safety and Health Administration, and 

JC standards. 

We inspected outpatient areas, the inpatient medical and 

surgical units, the intensive care unit (ICU), the telemetry 

unit, and the CLC. Also, we reviewed the IC program. The 

medical center maintained a generally clean and safe 

environment. Nurse managers and unit staff expressed 

satisfaction with the responsiveness of the housekeeping 

staff on their units. We identified the following areas that 

needed improvement: 

VA Office of Inspector General 5 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

VA Office of Inspector General 6 

Medication Refrigerator Monitoring. Staff did not consistently 

clean medication refrigerators weekly to maintain sanitary 

cold storage, as required by local policy. Two of three 

medication refrigerators were not clean, and unit managers 

had not developed a system to monitor cleaning. 

Hand Hygiene. The local hand hygiene policy did not 

include all VHA requirements. VHA requires3

 that the local 

policy include the requirement that the medical center 

monitor health care workers’ hand hygiene adherence and 

provide them with information regarding their performance in 

order to reduce infection risks for patients and staff. IC staff 

placed overall hospital compliance percentages on a shared 

drive, but information was not unit or individual specific. 

Health care staff that we interviewed rarely accessed the 

shared drive and were not aware of their performance. 

Hazardous Spill Containment. During interviews, staff on 

two units were unable to correctly verbalize the local policy 

on actions to take in the event of a hazardous spill, such as 

blood. Unit managers need to ensure that staff are educated 

about proper hazardous spill procedures. 

Safety. Facility Management Service staff had not 

performed a system maintenance test for the electronic 

patient elopement system—used to alert staff that high-risk 

patients have left their unit without supervision—since 2004. 

Health care staff did not test the monitored doors or sensors 

in accordance with the manufacturer’s recommendations to 

ensure that the system was working. Without appropriate 

testing, staff could not be assured that the system was 

functional. 

Electrical Hazards. The medical center environmental 

rounds team conducted weekly environmental rounds as 

required by VHA. However, we found a compact disc player 

plugged into an electrical outlet and suspended by a string 

over a whirlpool bathtub. Also, we found a coffee pot and a 

microwave oven plugged into an extension cord that was 

plugged into an adapter and then into an electrical outlet. 

Practices like these can lead to electrical injuries and create 

fire hazards. These electrical hazards had not been 

identified during environmental rounds. 

 

3

 VHA Directive 2005-002, Required Hand Hygiene Practices, January 13, 2005. 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

Recommendation 3 We recommended that the VISN Director ensure that the 

Medical Center Director requires staff to maintain medication 

refrigerator cleanliness in accordance with local policy. 

The VISN and Medical Center Directors concurred with our 

findings and recommendation. Local policy has been 

revised to include cleaning timeliness, and staff have been 

educated on the policy and process. Also, a monitor for 

refrigerator cleaning is in place. We find this action plan 

appropriate and will follow up on reported implementation 

actions to ensure completion. 

Recommendation 4 We recommended that the VISN Director ensure that the 

Medical Center Director requires that the local hand hygiene 

policy includes a requirement to monitor health care workers’ 

adherence to hand hygiene practices and that health care 

workers are provided with information regarding their 

performance. 

The VISN and Medical Center Directors concurred with our 

findings and recommendation. The local policy is being 

revised, and supervisors are now responsible for sharing 

hand hygiene performance results with staff. We find this 

action plan appropriate and will follow up on reported 

implementation actions to ensure completion. 

Recommendation 5 We recommended that the VISN Director ensure that the 

Medical Center Director requires that staff are aware of the 

procedures to follow in the event of a hazardous spill. 

The VISN and Medical Center Directors concurred with our 

findings and recommendation. Information has been 

provided to staff to re-educate them on response procedures 

for hazardous spills. We find this action plan appropriate 

and will follow up on reported implementation actions to 

ensure completion. 

Recommendation 6 We recommended that the VISN Director ensure that the 

Medical Center Director requires that staff monitor and test 

the electronic elopement system according to the 

manufacturer’s recommendations. 

The VISN and Medical Center Directors concurred with our 

finding and recommendation. Staff are completing daily, 

weekly, and monthly checks of the elopement system. 

Preventive maintenance has been scheduled on a quarterly 

basis in accordance with the manufacturer’s 

VA Office of Inspector General 7 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

recommendations. We find this action plan appropriate and 

will follow up on reported implementation actions to ensure 

completion. 

Recommendation 7 We recommended that the VISN Director ensure that the 

Medical Center Director requires that staff use electrical 

appliances safely. 

The VISN and Medical Center Directors concurred with our 

findings and recommendation. Staff will be re-educated on 

electrical safety, and environmental rounds will assess 

compliance on an ongoing basis. We find this action plan 

appropriate and will follow up on reported implementation 

actions to ensure completion. 

Coordination of 

Care 

The purpose of this review was to evaluate whether inpatient 

consultations, transfers, and discharges were coordinated 

appropriately 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 reviewed the medical records of 15 inpatients who had 

consults ordered and performed internally. In general, we 

found that inpatients received consultative services within 

acceptable timeframes. We identified the following areas 

that needed improvement: 

Transfer Documentation. We found that 4 (27 percent) of 

15 intra-facility transfers did not have the required medical 

record documentation specified by local policy. Two did not 

include nursing notes, and the other two did not include 

physician notes. Local policy requires that nursing staff and 

physicians complete a transfer note each time a patient is 

transferred within the facility. 

Discharge Documentation. We found that 2 (13 percent) of 

15 records did not have patient discharge instructions that 

were consistent with the patient discharge summary. Also, 

4 (27 percent) of 15 records did not have discharge 

education documented by nursing staff. JC standards 

require individualized patient education prior to discharge, 

and local policy requires that nursing staff document 

discharge education for each patient. Documentation and 

communication of patient health information enhances 

continuity and coordination of care. 

VA Office of Inspector General 8 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

Recommendation 8 We recommended that the VISN Director ensure that the 

Medical Center Director requires staff to consistently 

complete intra-facility transfer documentation, as required by 

local policy. 

The VISN and Medical Center Directors concurred with our 

finding and recommendation. Templates are in place for 

documentation of intra-facility transfers. Compliance will be 

monitored, and results will be reported through the Quality 

Performance Council. We find this action plan appropriate 

and will follow up on reported implementation actions to 

ensure completion. 

Recommendation 9 We recommended that the VISN Director ensure that the 

Medical Center Director requires staff to consistently 

complete discharge documentation, as required by JC 

standards and local policy. 

The VISN and Medical Center Directors concurred with our 

findings and recommendation. Supervisors have stressed 

the importance of using the discharge template for 

documentation. Use of the template will be monitored, and 

results will be reported through the Quality Performance 

Council. We find this action plan appropriate and will follow 

up on reported implementation actions to ensure completion. 

Emergency/Urgent 

Care Operations 

The purpose of this review was to evaluate whether VHA 

facility E/UC operations complied with VHA guidelines 

related to hours of operation, clinical capability (including 

management of patients with acute mental health conditions 

and patients transferred to other facilities), staffing 

adequacy, and staff competency. In addition, we inspected 

the medical center’s ED for cleanliness and safety. 

The ED is located within the main hospital building and is 

open 24 hours per day, 7 days per week. The emergency 

services provided are within the medical center’s patient care 

capabilities. 

We reviewed medical records of patients who presented in 

the ED with acute mental health conditions, and in all cases, 

we found that staff managed the patients’ care appropriately. 

We reviewed the ED nurse staffing plan and time schedules 

and determined that managers had consistently followed 

their established staffing guidelines for allocating nursing 

VA Office of Inspector General 9 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

VA Office of Inspector General 10 

resources. We also found that managers had appropriately 

documented nurse competencies. 

We determined that the ED complied with VHA operational 

standards, including staffing guidelines, cleanliness, and 

competency. However, the following area needed 

improvement: 

Inter-Facility Transfers. ED staff did not document specific 

inter-facility transfer data, as required by VHA and local 

policy.4 The movement of acutely ill patients from one 

institution to another exposes them to risks. Failing to 

transfer patients may be equally risky. VHA has the 

responsibility to ensure that transfers into and out of its 

medical facilities are carried out appropriately to assure 

maximum patient safety and to comply with the intent of the 

Emergency Medical Treatment and Labor Act. 

None of the medical records we reviewed contained all the 

required documentation elements. During onsite interviews, 

ED staff located and identified their local inter-facility transfer 

policy, and they provided paper forms that contained all 

required documentation elements. However, staff stated that 

they only began using the forms 2 weeks prior to our site 

visit. We were told that there are plans to develop an 

electronic inter-facility transfer template. 

Recommendation 10 We recommended that the VISN Director ensure that the 

Medical Center Director requires ED staff to complete 

inter-facility transfer documentation, as required by VHA and 

local policy. 

The VISN and Medical Center Directors concurred with our 

findings and recommendation. ED staff are now using the 

national template for documentation of inter-facility transfers. 

Compliance will be monitored. We find this action plan 

appropriate and will follow up on reported implementation 

actions to ensure completion. 

Medication 

Management 

The purpose of this review was to evaluate whether VHA 

facilities had adequate medication management practices. A 

safe medication management system includes medication 

ordering, administering, and monitoring. 

 

4

 VHA Directive 2007-015, Inter-Facility Transfer Policy, May 7, 2007. 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

We reviewed selected medication management processes in 

the inpatient medical and surgical units, the ICU, the 

telemetry unit, and the CLC. We found adequate 

management of medications brought into the facility by 

patients or their families. Nurses appropriately scanned 

patient armbands and used personal identifiers to correctly 

identify patients prior to medication administration. We 

identified the following area that needed improvement: 

Documentation of Pain Medication Effectiveness. On the 

inpatient units we reviewed, nurses did not consistently 

document the effectiveness of pain medications in 

accordance with local policy requirements. We reviewed the 

Bar Code Medication Administration records for 15 patients 

who were hospitalized in selected units at the time of our 

visit. For each patient, we reviewed documentation for 

several doses of pain medication. Nurses did not 

consistently document the effectiveness of pain medications 

within 4 hours in 12 (80 percent) of the 15 patients, as 

required by local policy. Without appropriate follow-up and 

consistent documentation, clinicians could not be assured 

that patients’ pain was effectively managed. 

Recommendation 11 We recommended that the VISN Director ensure that the 

Medical Center Director requires that nurses consistently 

document the effectiveness of all pain medications within the 

required timeframe of the local policy. 

The VISN and Medical Center Directors concurred with our 

finding and recommendation. The local policy and the 

documentation template will be reviewed and then modified 

as needed. Timeliness of documentation will be monitored. 

We find this action plan appropriate and will follow up on 

reported implementation actions to ensure completion. 

Pharmacy 

Operations 

The purpose of this review was to evaluate whether VA 

health care facilities had adequate controls to ensure the 

security and proper management of controlled substances 

and the pharmacies’ internal physical environments. We 

also determined whether clinical managers had processes in 

place to monitor patients prescribed multiple medications to 

avoid polypharmacy, especially in vulnerable populations. 

We assessed whether the medical center’s policies and 

practices were consistent with VHA regulations governing 

VA Office of Inspector General 11 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

VA Office of Inspector General 12 

pharmacy and controlled substances security.5 In addition, 

we reviewed policies and procedures and interviewed 

appropriate personnel to determine if clinical pharmacists 

monitored patients prescribed multiple medications to avoid 

polypharmacy. We inspected inpatient and outpatient 

pharmacy operations for security, EOC, and IC concerns, 

and we interviewed appropriate Pharmacy Service personnel 

as necessary. 

Pharmacy Controls. The medical center had appropriate 

policies and procedures to ensure the security of the 

pharmacy and controlled substances. The internal 

environments for the inpatient and outpatient pharmacies 

were secure, clean, and well maintained with the exception 

of the pharmacy vault day gate. The day gate in the 

pharmacy vault would not close automatically upon entry. 

Staff had to close the gate manually to engage the lock. 

VHA requires an automatic closing and locking day gate to 

ensure the security of bulk controlled substances. Medical 

center staff repaired the day gate during our review; 

therefore, we made no recommendation. 

Polypharmacy. 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.6 Some literature suggests that 

elderly patients and mental health patients are among the 

most vulnerable populations for polypharmacy.7

 Clinical 

pharmacists identified all patients who were prescribed 

multiple medications, reviewed their medication regimens to 

 

5

 VHA Handbook 1108.1, Controlled Substances (Pharmacy Stock), October 4, 2004; VHA Handbook 1108.2, 

Inspection of Controlled Substances, August 29, 2003; VHA Handbook 1108.5, Outpatient Pharmacy, 

May 30, 2006; VHA Handbook 1108.6, Inpatient Pharmacy, June 27, 2006. 6

 Yvette C. Terrie, BSPharm, RPh, “Understanding and Managing Polypharmacy in the Elderly,” Pharmacy Times,

December 2004. 

7

 Terrie, Pharmacy Times, December 2004; Vijayalakshmy Patrick, M.D., et al., “Best Practices: An Initiative to 

Curtail the Use of Antipsychotic Polypharmacy in a State Psychiatric Hospital,” Psychiatric Services, 57:21–23, 

January 2006. 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

VA Office of Inspector General 13 

avoid polypharmacy, and advised providers as appropriate. 

We identified the following area that needed improvement: 

Controlled Substances Inspections. While assigned staff 

conducted the inspections according to VHA regulations, and 

training records documented that the CSC, the alternate 

CSC, and all inspectors received appropriate training to 

execute their duties, we noted an area of the program that 

did not meet VHA regulations. The CSC, with approval from 

the medical center’s Director, initiated and signed the 

controlled substances inspectors’ appointment letters. VHA 

regulations8 state that medical center Directors have the 

responsibility to initiate and sign all appointment letters. 

Recommendation 12 We recommended that the VISN Director ensure that the 

Medical Center Director initiates and signs appointment 

letters for the alternate CSC and controlled substances 

inspectors. 

The VISN and Medical Center Directors concurred with our 

finding and recommendation. The Medical Center Director 

reissued the November 2008 appointment letters with his 

signature. We find this action plan appropriate and will 

follow up on reported implementation actions to ensure 

completion. 

Review Activities Without Recommendations 

Staffing The purpose of this review was to evaluate whether VHA 

facilities had developed comprehensive staffing guidelines 

and whether the guidelines had been met. We found that 

the medical center had developed a Nursing Service staffing 

plan and unit-based nurse staffing guidelines, and we found 

them to be adequate. 

The medical center uses staff/patient/acuity ratio as the 

primary staffing methodology. Nurse managers adjust 

staffing shift-by-shift based on patient acuity levels; average 

daily census; and frequency of patient admissions, transfers, 

and discharges. The Nursing Service staffing plan is 

reviewed and adjusted annually. 

We reviewed staffing for all inpatient units for a total of 

27 shifts. We looked at one holiday, one Sunday, and one 

Tuesday for all units. We found that local guidelines for 

 

8

 VA Handbook 0730. 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

nurse staffing were met in all areas reviewed and that 

specific actions had been taken to ensure safe patient care, 

including the use of compensatory time and overtime when 

needed. We found nurse staffing adequate in all patient care 

areas. We made no recommendations. 

Survey of 

Healthcare 

Experiences of 

Patients 

The purpose of this review was to assess the extent that 

VHA medical centers use quarterly survey results of patients’ 

health care experiences with the VHA system 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 goals for patients reporting overall satisfaction of 

“very good” or “excellent” at 76 percent for inpatients and 

77 percent for outpatients. Medical centers are expected to 

address areas that fall below target scores. 

We reviewed the inpatient and outpatient survey results for 

each quarter, beginning with the 3rd quarter of FY 2006 and 

ending with the 2nd quarter of FY 2008. Figure 1 below and 

Figure 2 on the next page show the medical center’s SHEP 

performance measure results for inpatients and outpatients, 

respectively. 

Facility

VA Office of Inspector General 14 

60

65

70

75

80

85

90

95

100

Qtr 3 (FY 06) 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)

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

VISN

National

ROBERT J. DOLE VA MEDICAL CENTER 

WICHITA, KANSAS

INPATIENT OVERALL QUALITY BY QUARTER

Meets 

Target

Figure 1:
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

60

65

70

75

80

85

90

95

100

Qtr 3 (FY 06) 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)

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

Facility

VISN

National

ROBERT J. DOLE VA MEDICAL CENTER 

WICHITA, KANSAS

OUTPATIENT OVERALL QUALITY BY QUARTER

Figure 2:

Meets 

Target

The medical center fell below target levels in 4 of the 

8 quarters reviewed for inpatient overall quality and 3 of the 

8 quarters reviewed for outpatient overall quality. The 

medical center’s Director shared SHEP data with staff, 

service chiefs, and patients. Communication, coordination of 

care, and emotional support were identified as areas 

needing improvement in the inpatient units. The 

reorganization of primary care, the transfer of responsibility 

for phone calls to primary care teams, and the 30-day open 

access for appointments contributed to the decreased 

outpatient scores. All data was analyzed, actions were 

taken, and plans were appropriate and effective; therefore, 

we made no recommendations.

VA Office of Inspector General 15 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 16 

Department of 

Veterans Affairs Memorandum 

Date: February 4, 2009

From: Director, VA Heartland Network (10N15) 

Subject: Combined Assessment Program Review of the 

Robert J. Dole VA Medical Center, Wichita, Kansas 

To: Director, Kansas City Healthcare Inspections Division 

(54KC) 

Director, Management Review Service (10B5) 

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

Combined Assessment Program (CAP) review of the Robert J. Dole VA 

Medical Center, Wichita, Kansas, dated January 23, 3009. I concur with 

the implementation plans as described and the established target dates. 

2. The medical center carefully reviewed all items identified as 

opportunities for improvement and concurred in the recommendations that 

were made. 

3. If you have additional questions, or need additional information, please 

contact Mary Steiner at 316.685.2221. 

James R. Floyd, FACHE 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

Appendix B 

Medical Center Director Comments 

VA Office of Inspector General 17 

Department of 

Veterans Affairs Memorandum 

Date: February 2, 2009

From: Director, Robert J. Dole VA Medical Center (589A7/00) 

Subject: Combined Assessment Program Review of the 

Robert J. Dole VA Medical Center, Wichita, Kansas 

To: Director, VA Heartland Network (10N15) 

I concur with the findings and recommendations of the CAP Review. 

THOMAS J. SANDERS, FACHE 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

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 VISN Director ensure 

that the Medical Center Director requires that all medical center 

employees who require CPR and AED training have current certification. 

Concur April 1, 2009 

In progress. Action has been started for current certification of VA Police 

staff. Education Service is refining the tracking system for CPR 

certification. Effectiveness will be monitored. 

Recommendation 2. We recommended that the VISN Director ensure 

that the Medical Center Director requires that the local CPR policy is 

modified to include all employees who require training and to define the 

process for tracking current training. 

Concur April 1, 2009 

The local policy is being reviewed to determine clinically active staff, as 

well as any additional staff that may require CPR training. The process for 

tracking current CPR is being developed by Education Service. The 

effectiveness of the tracking system will be monitored. 

Recommendation 3. We recommended that the VISN Director ensure 

that the Medical Center Director requires staff to maintain medication 

refrigerator cleanliness in accordance with local policy. 

Concur April 1, 2009 

The policy for maintenance and cleaning of the patient care refrigerators 

(including medication refrigerators) has been revised to include cleaning 

timeliness. Education on the policy and process has been completed. 

The monitoring for medication refrigerator cleaning is in place. 

Recommendation 4. We recommended that the VISN Director ensure 

that the Medical Center Director requires that the local hand hygiene 

policy includes a requirement to monitor health care workers’ adherence 

to hand hygiene practices and that health care workers are provided with 

information regarding their performance. 

VA Office of Inspector General 18 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

Concur March 1, 2009 

The local hand hygiene policy is being reviewed and revised. Monitoring 

continues to occur and supervisory personnel are responsible (per revised 

policy) for sharing information with staff on staff performance based on the 

monitoring results. 

Recommendation 5. We recommended that the VISN Director ensure 

that the Medical Center Director requires that staff are aware of the 

procedures to follow in the event of a hazardous spill. 

Concur March 1, 2009 

Policies are currently being reviewed and will be revised for further 

clarification as needed. A memorandum has been sent to re-educate staff 

on procedures for response to hazardous spills. 

Recommendation 6. We recommended that the VISN Director ensure 

that the Medical Center Director requires that staff monitor and test the 

electronic elopement system according to the manufacturer’s 

recommendations. 

Concur June 15, 2009 

In progress. Daily, weekly and monthly checks are being completed by 

staff. Preventive maintenance (PM) is scheduled on a quarterly basis per 

manufacturer’s directions. PM will be reported for two quarters to ensure 

effectiveness. 

Recommendation 7. We recommended that the VISN Director ensure 

that the Medical Center Director requires that staff use electrical 

appliances safely. 

Concur Re-education by March 1, 2009 

Staff will be re-educated on electrical safety. Environmental rounds will 

assess compliance on an ongoing basis. 

Recommendation 8. We recommended that the VISN Director ensure 

that the Medical Center Director requires staff to consistently complete 

intra-facility transfer documentation, as required by local policy. 

Concur June 1, 2009 

Transfer templates are being utilized for intra-facility transfer 

documentation. Education has been given to appropriate staff. 

Monitoring for compliance will occur and be reported through the Quality 

Performance Council. 

VA Office of Inspector General 19 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

VA Office of Inspector General 20 

Recommendation 9. We recommended that the VISN Director ensure 

that the Medical Center Director requires staff to consistently complete 

discharge documentation, as required by JC standards and local policy. 

Concur June 1, 2009 

Use of the discharge template has been re-emphasized by supervisory 

staff and monitoring of the use and appropriate discharge documentation 

will be reported to Quality Performance Council. 

Recommendation 10. We recommended that the VISN Director ensure 

that the Medical Center Director requires ED staff to complete 

inter-facility transfer documentation, as required by VHA and local policy. 

Concur June 1, 2009 

The Emergency Department are now consistently using the national 

template for documentation of inter-facility transfers. Education has been 

provided to all ED providers. Monitoring will be done for compliance. 

Recommendation 11. We recommended that the VISN Director ensure 

that the Medical Center Director requires that nurses consistently 

document the effectiveness of all pain medications within the required 

timeframe of the local policy. 

Concur July 1, 2009 

The policy and documentation template will be reviewed and modified as 

needed for possible modification. Monitoring will reflect timeliness per our 

policy for evaluation of effectiveness of pain medication. 

Recommendation 12. We recommended that the VISN Director ensure 

that the Medical Center Director initiates and signs appointment letters for 

the alternate CSC and controlled substances inspectors. 

Concur Completed 

The controlled substances inspector’s appointment letters issued in 

November 2008 were reissued by the Medical Center Director with his 

signature. 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

Appendix C 

VA Office of Inspector General 21 

OIG Contact and Staff Acknowledgments 

Contact Virginia L. Solana, Director 

Kansas City Office of Healthcare Inspections 

(816) 997-6971 

Contributors Dorothy Duncan, Team Leader 

Stephanie Hensel 

Jennifer Kubiak 

Reba B. Ransom 

James Seitz 

James Werner, Office of Investigations 
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas 

Appendix D 

VA Office of Inspector General 22 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Heartland Network (10N15) 

Director, Robert J. Dole VA Medical Center (589/00) 

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: Sam Brownback, Pat Roberts 

U.S. House of Representatives: Lynn Jenkins, Dennis Moore, Jerry Moran, Todd Tiahrt 

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