Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 08-03083-17

Combined Assessment Program 

Review of the 

Marion VA Medical Center 

Marion, Illinois 

November 2, 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 Marion VA Medical Center, Marion, Illinois 

Table of Contents 

Page 

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

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

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

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

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

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

Quality Management ........................................................................................ 3

Physician Credentialing and Privileging ............................................................ 12

Environment of Care ......................................................................................... 13

Medication Management .................................................................................. 16

Review Activities Without Recommendations ........................................................ 17

Coordination of Care ........................................................................................ 17

VHA Satisfaction Surveys ...................................................................................... 17

Appendixes

A. VISN Director Comments ................................................................................. 19

B. Medical Center Director Comments .................................................................. 20

C. OIG Contact and Staff Acknowledgments ........................................................ 29

D. Report Distribution ............................................................................................ 30

VA Office of Inspector General 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

Executive Summary 

Introduction During the week of August 17–21, 2009, the OIG conducted 

a Combined Assessment Program (CAP) review of the 

Marion VA Medical Center (the medical center), Marion, IL. 

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 about 

60 medical center employees. The medical center is part of 

Veterans Integrated Service Network (VISN) 15. 

Results of the 

Review 

The CAP review covered five operational activities. We 

made recommendations in four of the activities reviewed. 

For these activities, medical center managers needed to 

ensure compliance with Veterans Health Administration 

(VHA) policies and other external standards related to: 

• QM. 

• Physician Credentialing and Privileging (C&P). 

• Environment of Care (EOC). 

• Medication Management. 

The medical center complied with selected standards in the 

following activity: 

• Coordination of Care. 

This report was prepared under the direction of 

Victoria Coates, Director, Atlanta Office of Healthcare 

Inspections. 

Comments The VISN and Medical Center Directors agreed with the CAP 

review findings and recommendations. While we disagree 

that the medical center had fully functioning programs and 

processes in place at the time of our review, the 

improvement plans provided are acceptable. (See 

Appendixes A and B, pages 19–28, for the full text of the 

Directors’ comments.) We will follow up on the planned 

VA Office of Inspector General i
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

VA Office of Inspector General ii

actions until they are completed, and we will evaluate the 

effectiveness of those actions at periodic intervals to ensure 

that the identified conditions have been corrected. 

 (original signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

Introduction 

Profile Organization. The medical center is located in Marion, IL, 

and provides a broad range of inpatient and outpatient 

health care services. Outpatient care is also provided at 

eight community based outpatient clinics in Effingham and 

Mt. Vernon, IL; Vincennes and Evansville, IN; and 

Owensboro, Hanson, Paducah, and Mayfield, KY. The 

medical center is part of VISN 15 and serves a veteran 

population of about 127,000 throughout 52 counties in 

southern Illinois, southeastern Indiana, and western 

Kentucky. 

Programs. The medical center provides primary, specialty, 

and inpatient care; physical medicine and rehabilitation; 

neurology, oncology, cardiology, surgery, and urology 

services; pain management; behavioral health (BH); and 

geriatrics and extended care. It has 55 hospital beds and 

60 community living center (CLC) beds. 

Affiliations and Research. The medical center is affiliated 

with Saint Louis University and Southern Illinois University 

and provides training for six residents in cardiology and 

ophthalmology. The medical center does not have a 

research program. 

Resources. In fiscal year (FY) 2008, medical care 

expenditures totaled approximately $176.7 million. The 

FY 2009 medical care budget was about $188.4 million. 

FY 2008 staffing was 1,020 full-time employee equivalents 

(FTE), including 70 physician and 345 nursing FTE. 

FY 2009 staffing was approximately 1,310 FTE, including 

111 physician and 455 nursing FTE. 

Workload. In FY 2008, the medical center treated 

approximately 42,000 unique patients and provided about 

13,000 hospital inpatient days of care. The hospital 

inpatient care workload totaled about 2,900 discharges, and 

the hospital average daily census was 37. The CLC 

provided about 21,000 inpatient days of care and had an 

average daily census of 58. Outpatient workload totaled 

about 352,000 visits. FY 2009 workload data was not yet 

available at the time of this report. 

VA Office of Inspector General 1 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

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 five activities: 

• Coordination of Care.

• EOC.

• Medication Management. 

• Physician C&P. 

• QM. 

The review covered medical center operations for FY 2008 

and FY 2009 through August 21, 2009, and was done in 

accordance with OIG standard operating procedures for 

CAP reviews. We also followed up on selected 

recommendations from three previous reports: 

• Combined Assessment Program Review of the 

VA Medical Center, Marion, Illinois, Report 

No. 05-03486-93, February 21, 2006. There were no 

health care related recommendations from our prior 

CAP review. 

VA Office of Inspector General 2 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

• Assessment of Legionnaire’s Disease Risk in Veterans 

Health Administration Inpatient Facilities, Report 

No. 07-00029-151, June 20, 2007. We found that the 

medical center was in compliance with the 

recommendations. 

• Quality of Care Issues, VA Medical Center, Marion, 

Illinois, Report No. 07-03386-65, January 28, 2008, 

(hereinafter referred to as the January 2008 Hotline 

report). We found that many of the previously identified 

issues had been corrected; however, several QM and 

C&P conditions still existed. Those repeat findings will 

be discussed further in the next section of this report. In 

addition, we noted that all of the medical center’s senior 

leadership positions and many of the key service chief 

positions had experienced turnover in the past 2 years. 

During this review, we also presented fraud and integrity 

awareness briefings for about 60 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 findings 

requiring corrective actions.

Results 

Review Activities With Recommendations 

Quality 

Management 

The purposes of this review were to determine whether 

(a) the medical center had a comprehensive and effective 

QM program designed to monitor patient care activities and 

coordinate improvement efforts and (b) senior managers 

actively supported QM efforts and appropriately responded 

to QM results. To evaluate QM processes, we interviewed 

senior managers, QM staff, and other knowledgeable 

personnel. In addition, we reviewed the self-assessment 

regarding compliance with QM requirements as well as 

committee minutes and other relevant QM documents. 

VA Office of Inspector General 3 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

VA Office of Inspector General 4 

We evaluated 13 QM areas and found that patient 

complaints and patient safety goals related to 

anticoagulation and medication reconciliation were 

monitored appropriately. However, we determined that the 

medical center did not fully comply with VHA guidelines, 

resulting in deficiencies in the remaining 10 QM areas we 

reviewed. We noted that several QM-specific corrective 

actions initiated in response to the January 2008 Hotline 

report had not been fully implemented and did not 

consistently correct the conditions identified. We also noted 

that conditions identified in the January 2008 Hotline report 

still existed in the areas of QM oversight structure, peer 

review, mortality assessment, patient safety, and adverse 

event disclosure. 

The remainder of the QM section discusses those repeat 

findings from the January 2008 Hotline report, conditions 

newly identified during this CAP review, and the overall 

status of the medical center’s QM Program. 

Repeat Quality 

Management Findings

Committee Oversight Structure. The medical center’s QM 

oversight and reporting structure was fragmented and 

inconsistent, making it difficult to determine the extent of 

oversight or the corrective actions taken to improve patient 

care. A functional and accountable QM oversight structure 

assures that oversight committees and their subordinate 

committees are monitoring, analyzing, and reporting 

according to guidelines and that recommendations and 

corrective actions are appropriately followed up. Also, the 

medical center’s committee oversight structure was not fully 

integrated or functional, as evidenced by the span of 

deficiencies across multiple QM areas. See Table A on 

page 10 for further details. 

Peer Review. The peer review program had a designated 

Peer Review Committee (PRC), and local policy was in 

compliance with VHA requirements. However, we found 

that the medical center had an inadequate peer review 

process, resulting in the following deficiencies: 

• Backlog of Cases. Peer review cases were not 

completed within the required 45- or 120-day 

timeframes, as required by VHA policy.1

 Medical center 

staff provided us with the most recent available 

 

1

 VHA Directive 2008-004, Peer Review for Quality Management, January 28, 2008. This is the reference for all 

peer review related findings in this section unless otherwise indicated. 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

VA Office of Inspector General 5 

data, a 1st quarter FY 2009 report showing that 

13 (17 percent) of the 75 initial peer reviews were not 

completed within 45 days. In addition, the PRC had not 

finalized 18 (34 percent) of 53 final peer reviews within 

120 days. The Peer Review Coordinator told us that the 

PRC had been meeting twice a week to decrease the 

case backlog and to improve timeliness of final peer 

reviews. However, we were not provided with 

documentation reflecting the current status of the 

backlog or the current timeliness of peer reviews. 

• Process and/or System Issues. Communication was 

inadequate, and case referral systems were inefficient. 

For example, the PRC did not refer patient safety 

related process and/or system issues to the Patient 

Safety Manager (PSM). The PRC maintained a list of 

process and/or system issues identified during peer 

reviews. However, the list was not provided to the PSM, 

and the PSM was not included in discussions to 

determine the need for a root cause analysis (RCA) or 

other review. VHA policy requires that process and/or 

system issues identified through peer review be referred 

for appropriate evaluation. 

Also, we identified 27 cases listed in the February 2009 

Operative and Other Invasive Procedure Review 

Committee minutes with events that occurred between 

May 2007 and January 2009. However, we could not 

validate whether the cases had actually been referred to 

the PRC. VHA policy requires that a peer review level 

be assigned to cases meeting screening criteria. 

Mortality Assessment. Mortality screening criteria did not 

include all required elements, and mortality reports did not 

include trending by service or by provider, as required by 

VHA policy. We also found that a critical analysis of 

deaths completed by QM staff was inadequate and that the 

number of reported deaths was inconsistent. 

2

• Inadequate Screening. The medical center was using 

mortality screening criteria from an outdated VHA 

directive and, as a result, did not screen for deaths 

within 30 days of surgical procedures, as required by 

current VHA policy. Surgical Service staff were aware 

of two deaths occurring after surgical procedures, but it 

 

2

 VHA Directive 2005-056, Mortality Assessment, December 1, 2005. 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

VA Office of Inspector General 6 

does not appear that the information was provided to 

QM staff. Thus, the deaths were not included in monthly 

mortality reports. 

• Critical Analysis. Mortality data were not always 

critically analyzed when a specific concern was 

identified. For example, QM staff evaluated 16 deaths 

that occurred on a particular unit between January and 

July 2009. QM staff limited the review criteria to 

include: (a) change in patient’s condition, (b) age, 

(c) terminal status, (d) hospice enrollment, and 

(e) do-not-resuscitate status. The report to medical 

center managers showed that these deaths were 

associated with a terminal illness and that no trends 

existed. 

QM staff noted in the margins or in the comments 

sections of their worksheets that 3 (19 percent) 

of the 16 patients had some type of infection prior to 

death. However, QM staff were unable to tell us 

whether these deaths were related to infections since 

they had not included that criterion in their review. In 

addition, they could not say whether the infections 

represented a pattern or cluster, signifying an infection 

control problem. 

• Validation. The number of deaths at the medical center 

was inconsistently reported. For example, Clinical 

Executive Board (CEB) minutes documented that there 

were five deaths in April 2009. However, the Patient 

Movement Statistics Report listed six deaths, and the 

Gains and Losses sheets showed seven deaths. Staff 

were unable to describe the methods used to validate 

mortality data. 

Patient Safety. The patient safety program was not 

integrated into all areas of the medical center, and tracking 

of completed actions and evaluation of outcomes were 

incomplete and inconsistent. We also found that a 

comprehensive report had not been presented to senior 

managers, as required by VHA policy.3

• Integration. Patient safety was not integrated 

throughout the medical center. We interviewed the 

PSM, the Risk Manager, the Peer Review Coordinator, 

 

3

 VHA Handbook 1050.01, VHA National Patient Safety Improvement Handbook, May 23, 2008. 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

VA Office of Inspector General 7 

and other staff. During these interviews, it became clear 

that there was no process in place for consistent sharing 

of information between the various entities. Risk 

management and patient safety staff confirmed that they 

were unaware of several significant patient safety 

events that would have warranted further review. 

• Tracking. While staff told us that tracking had been 

documented in Patient Safety Council (PSC) minutes, 

we were unable to confirm this assertion. Our review of 

PSC minutes for the 12 months preceding our visit 

showed that reporting and tracking of RCA actions, 

evaluation of action effectiveness, and measurement of 

outcomes were sporadic. 

• Reporting. Significant issues from RCAs were not 

reported to clinical staff, and a comprehensive patient 

safety report had not been presented to senior 

managers in the previous 12 months. Reporting is to 

include patterns and trends as well as process and/or 

systems issues. For example, we found no evidence 

that senior managers were aware of actions taken (or 

not taken) in response to an RCA involving clinic 

cancellations and a subsequent adverse patient 

outcome. 

Adverse Events. The medical center was not in compliance 

with all elements of adverse event disclosure required by 

VHA policy.4 From September 2008–May 2009, 15 peer 

reviews were assigned a Level 3 rating (indicating that peer 

reviewers would have handled patient care differently). We 

randomly selected four of these peer reviews and found that 

only one of them had been evaluated for disclosure. Again, 

risk management and patient safety staff informed us that 

they were unaware of the cases and therefore had not 

evaluated them for disclosure. 

We also reviewed the three disclosure cases that the 

medical center did identify during FY 2009 through 

August 21, 2009. We found inconsistent decision criteria 

when determining the need for clinical versus institutional 

disclosure. In addition, we found delays in disclosure. In 

one case, disclosure occurred 2 months after discovery of 

the event; in another case, disclosure occurred 11 months 

after discovery of the event. As a result, we could not be 

 

4

 VHA Directive 2008-002, Disclosure of Adverse Events to Patients, January 18, 2008. 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

VA Office of Inspector General 8 

assured that events were evaluated properly to determine 

the need for disclosure or that disclosure would be timely 

should it be indicated. 

Newly Identified 

Quality Management 

Conditions

Medical Records. Service-level personnel did not conduct 

medical record reviews regularly, and the Medical Records 

Committee did not consistently receive data from clinical 

services. VHA policy5 requires ongoing medical record 

reviews by staff who document in the record to assess 

quality, consistency, accuracy, completeness, and 

authentication. 

In addition, the local computerized patient record system 

policy on the appropriate use of the copy and paste 

functions was just published in May 2009. Therefore, the 

medical center had not monitored the use of these functions 

in accordance with VHA policy. 

Operative and Other Invasive Procedure Review. 

Conscious sedation (CS) data were not trended or analyzed 

in accordance with VHA policy6 in all areas where moderate 

sedation was performed. 

Resuscitation and Its Outcomes. Local policy did not 

identify which medical center staff needed to maintain basic 

life support (BLS) or advanced cardiac life support (ACLS) 

certification. In addition, 4 (40 percent) of the 10 police 

officers had not received the required cardiopulmonary 

resuscitation (CPR) training. VHA policy7 requires that local 

policy designate staff who need to maintain BLS or ACLS 

certification and that all police officers receive CPR training. 

System Redesign/Patient Flow. Data analysis was 

inconsistent, and actions taken had not consistently been 

evaluated for effectiveness. 

Utilization Management. Data analysis was inconsistent, 

and actions taken had not consistently been evaluated for 

effectiveness. 

 

5

 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 6

 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2006. 7

 VHA Directive 2008-008, Cardiopulmonary Resuscitation (CPR) and Advanced Cardiac Life Support (ACLS) 

Training for Staff, February 6, 2008. 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

Overall Quality 

Management Program 

Status

We found that the medical center did not have a 

comprehensive and effective QM program that adequately 

monitored patient care activities and coordinated 

improvement efforts. The oversight reporting structure for 

QM reviews was fragmented and inconsistent, and 

accountability for quality monitoring and performance 

improvement activities appeared limited. These 

deficiencies, coupled with a lack of accurate data, seriously 

hindered senior managers’ abilities to make reasonable, 

data-driven decisions and to respond to QM results. 

Table A on the next page illustrates the extent to which the 

various types of deficiencies spanned multiple QM program 

areas. Repeat findings from the January 2008 Hotline 

report are denoted with an “R” in bold font. 

Deficiencies generally fell into one of the following 

categories as defined by VHA policy, external accrediting 

body standards, or local policies: 

• Integration and Comprehensiveness of QM Program.

The QM program should include specific elements to 

monitor and evaluate QM activities across the 

organization. 

• Documentation of Conclusions, Recommendations, and 

Corrective Action Completion. Identified QM 

improvement initiatives require documentation of 

conclusions, recommendations, and corrective actions. 

• Reporting to and/or Evaluation by an Oversight 

Committee. Routine evaluation of important QM 

monitors by an oversight committee is required to 

ensure evaluation of improvement opportunities and 

implementation of appropriate actions. 

• Data Trending, Analysis, and Reporting. To identify 

improvement opportunities, the QM program should 

evaluate trends, analyze data, and ensure reporting to 

appropriate medical center entities. 

VA Office of Inspector General 9 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

Table A. Matrix of QM-Wide Deficiencies 

QM REVIEW AREA

1 2 3 4 5 6 7 8 9 10 Oversight Structure Adverse Event Disclosure Medical Record Review Mortality Review Operative and Other Invasive Procedures Patient Safety Peer Review

Resuscitation and Its

Outcomes

System Redesign/

Patient Flow

Utilization

Management

QM program not

integrated or

comprehensive (does

not include all elements)

Fragmented and Inconsistent

X R X R R

Inadequate

documentation of

conclusions,

recommendations, and

corrective action

completion

X X X X X X X

Inadequate reporting to

and/or evaluation by an

oversight committee

R X R X X X

Inadequate data

trending, analysis, and

reporting

X R R X X X

We determined that an overall evaluation and redesign of 

the QM program is needed to promote communication and 

collaboration and to comply with VHA and external 

accreditation standards. Prior to leaving site, managers 

confirmed that efforts were underway to secure an 

experienced QM consultant who would take a leadership 

role in this endeavor. 

Recommendation 1 We recommended that the VISN Director ensure that the 

Medical Center Director requires an overall redesign of the 

QM oversight and reporting structure. 

The VISN and Medical Center Directors agreed with our 

findings and recommendation. While we disagree that the 

medical center had a functioning QM structure in place at 

the time of our review, the improvement plans provided are 

acceptable. The medical center has established a new 

governance structure and revised the QM policy to comply 

with VHA guidelines. We will follow up until the planned 

VA Office of Inspector General 10 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

actions are completed and quarterly monitors reflect that the 

actions have been effective. 

Recommendation 2 We recommended that the VISN Director ensure that the 

Medical Center Director requires the QM program to comply 

with VHA and local policies pertaining to: 

• Adverse Event Disclosure. 

• Medical Record Review. 

• Mortality Review. 

• Operative and Other Invasive Procedures. 

• Patient Safety. 

• Peer Review. 

• Resuscitation and Its Outcomes. 

• System Redesign/Patient Flow. 

• Utilization Management. 

The VISN and Medical Center Directors agreed with our 

findings and recommendation. While we disagree that the 

medical center had functioning processes in place at the 

time of our review, the improvement plans provided are 

acceptable. The medical center has revised policies to 

comply with VHA guidance, trained staff as indicated, and 

established a new committee oversight and accountability 

structure to monitor QM areas. We will follow up until the 

planned actions are completed and quarterly monitors 

reflect that the actions have been effective. 

We recommended that the VISN Director ensure that the 

Medical Center Director requires full integration of the 

patient safety program throughout the medical center. 

The VISN and Medical Center Directors agreed with our 

findings and recommendation. While we disagree that the 

medical center had an integrated patient safety program in 

place at the time of our review, the improvement plans 

provided are acceptable. The patient safety program has 

now been integrated into the governance structure and 

includes the required monthly and annual reporting. A 

SharePoint site has been established to facilitate integration 

and shared data between patient safety and QM staff. We 

will follow up until the planned actions are completed and 

quarterly monitors reflect that the actions have been 

effective. 

Recommendation 3 

VA Office of Inspector General 11 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

VA Office of Inspector General 12 

Recommendation 4 We recommended that the VISN Director ensure that the 

Medical Center Director requires routine collection, trending, 

analysis, and reporting of QM data. 

The VISN and Medical Center Directors agreed with our 

findings and recommendation. While we disagree that the 

medical center had a functioning QM structure in place at 

the time of our review, the improvement plans provided are 

acceptable. QM staff have received training in data 

analysis and data management tools, and a template has 

been implemented which standardizes meeting minutes and 

reporting to governing bodies. We will follow up until the 

planned actions are completed and quarterly monitors 

reflect that the actions have been effective. 

Recommendation 5 We recommended that the VISN Director ensure that the 

Medical Center Director requires that corrective actions 

relative to QM areas are evaluated for effectiveness and 

that outcomes are measured. 

The VISN and Medical Center Directors agreed with our 

findings and recommendation. While we disagree that the 

medical center had a functioning QM program in place at 

the time of our review, the improvement plans provided are 

acceptable. Evaluation of effectiveness will become a 

standard agenda item for governing bodies. QM experts 

provided training to key staff on how to collect, review, and 

analyze data using statistical and analytic tools for effective 

decision making. These QM experts will continue as 

consultants to the QM program and medical center 

leadership. We will follow up until the planned actions are 

completed and quarterly monitors reflect that the actions 

have been effective. 

Physician 

Credentialing and 

Privileging 

The purpose of this review was to determine whether the 

medical center complied with selected VHA8 and local 

policy requirements for the C&P of physicians. We 

reviewed C&P files and provider profiles for 23 physicians 

who were newly hired or reprivileged in the past 12 months. 

We also reviewed CEB meeting minutes, which include 

discussions about physicians’ privileges. 

We found that licenses were current and that primary 

source verification had been obtained for all physicians 

 

8

 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

included in our review. However, we identified the following 

areas that needed improvement. 

Practitioner Professional Practice Evaluation. Privileging is 

the process by which a facility determines what procedures 

a provider may perform based on clinical competency and 

the needs of the organization. VHA regulations and 

external accrediting bodies require a written plan with 

specific competency criteria for all privileged physicians. 

We found insufficient proctoring or monitoring information to 

confirm privilege-specific competency for 20 (87 percent) of 

the 23 physicians. In addition, we found that the CEB’s 

Professional Standards Session meeting minutes did not 

reflect detailed discussion of physicians’ performance data. 

This condition was also identified in the January 2008 

Hotline report. 

Physician Privileges. We found that two providers 

performed procedures for which they did not have 

privileges. One provider performed an arthroscopy (surgical 

procedure to view the inside of a joint through a viewing 

instrument); another provider administered CS to a patient 

on an inpatient medical unit. Local policy does not identify 

this unit as an area where CS can be administered. Neither 

patient suffered an adverse outcome as a result of their 

respective procedures. 

Recommendation 6 We recommended that the VISN Director ensure that the 

Medical Center Director requires that physician privileging 

processes comply with VHA requirements. 

The VISN and Medical Center Directors agreed with our 

findings and recommendation. While we disagree that the 

medical center had a functioning privileging program in 

place at the time of our review, the improvement plans 

provided are acceptable. Appropriate staff will be trained on 

the requirements for provider privileging, and actions will be 

monitored through the CEB. We will follow up until the 

planned actions are completed and quarterly monitors 

reflect that the actions have been effective. 

Environment of 

Care 

The purpose of this review was to determine whether the 

medical center complied with selected infection control 

standards and maintained a clean and safe health care 

environment. VHA facilities are required to provide a 

comprehensive EOC program that fully meets VHA, 

VA Office of Inspector General 13 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

VA Office of Inspector General 14 

Occupational Safety and Health Administration (OSHA), 

Centers for Disease Control (CDC) and Prevention, and 

other external accrediting body standards. 

We inspected inpatient medical wards 2A, 3A, and 3B, the 

intensive care unit, and the CLC. In addition, we inspected 

the emergency department and outpatient clinics.9 We 

found that the medical center maintained a generally clean 

environment and promoted hand and respiratory hygiene 

programs. However, we identified the following conditions 

that needed improvement. 

Safety. Medical center staff conducted EOC rounds; 

however, the system to document deficiencies and 

corrective actions was inadequate. Environmental 

Management Service (EMS) had responsibility for 

maintaining a list of the identified deficiencies, forwarding 

those deficiencies to appropriate staff or services for 

correction, and tracking those corrective actions through 

resolution. We found that EMS’s tracking record did not 

consistently reflect that EOC deficiencies were referred, that 

responsible people or services responded, or that deficient 

conditions were addressed and resolved. In addition, EOC 

Committee minutes did not reflect discussion, trending, or 

analysis of the deficiencies over time. We were told that 

Engineering Service would be assuming responsibility for 

this function. 

During our tour, we found the following conditions: 

• Electrically operated lifts in bathrooms were not 

connected to ground-fault circuit-interrupter (GFCI) 

protected receptacles. The National Fire Protection 

Association’s (NFPA’s) National Electrical Code requires 

installation of GFCI protection devices in bathrooms. 

While we were onsite, program managers began 

installation of GFCI protected receptacles. 

• Some storage areas in the medical center and the CLC 

did not meet NFPA standards. The standards require 

clearance of at least 18 inches between the ceiling and 

the top of stored items to allow sprinklers to work 

effectively in the event of a fire. 

 

9

 Gastroenterology, nephrology, renal, BH (including the Rural King building), primary care (including the Primary 

Care Annex), dermatology, and surgery. 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

VA Office of Inspector General 15 

• Egress corridors were cluttered with equipment. NFPA 

standards require that corridors be clear of obstructions 

in the event that emergency evacuation is required. 

Infection Control. Some practices and policies for infection 

control did not fully comply with VHA policy10 and CDC 

guidelines. We found examination tables with torn covers in 

two outpatient clinic areas. In addition, we found that a 

patient with a history of Methicillin-resistant Staphylococcus 

aureus (MRSA)11 and an order for contact precautions12

was inappropriately placed in a room that shared a 

bathroom with two patients who did not require contact 

precautions. 

Also, 7 (12 percent) of the 58 EMS employees did not 

receive training on cleaning and disinfection procedures, 

and 17 (29 percent) EMS employees did not receive annual 

training on the Bloodborne Pathogens Rule, as required by 

OSHA. 

Recommendation 7 We recommended that the VISN Director ensure that the 

Medical Center Director requires that deficiencies identified 

during EOC rounds are appropriately reported and that 

corrective actions are tracked through resolution. 

The VISN and Medical Center Directors agreed with our 

findings and recommendation and provided acceptable 

improvement plans. An EOC rounds tracking tool has been 

implemented, and a process has been established to report 

EOC findings to the Joint Leadership Council through the 

EOC Committee. We will follow up until the planned actions 

are completed and quarterly monitors reflect that the actions 

have been effective. 

Recommendation 8 We recommended that the VISN Director ensure that the 

Medical Center Director requires that all bathroom 

receptacles, storage areas, and corridors comply with NFPA 

requirements. 

The VISN and Medical Center Directors agreed with our 

findings and recommendation and provided acceptable 

improvement plans. The identified conditions have all been 

 

10 VHA Directive 2007-002, Methicillin-Resistant Staphylococcus Aureus (MRSA) Initiative, January 12, 2007. 11 MRSA refers to a bacterium that causes infection and has become resistant to commonly used antibiotics. 12 Contact precautions are steps taken, such as wearing gloves and gown, to reduce the risk of transmission of 

infection through direct and indirect contact.
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

corrected, and ongoing compliance will be monitored 

through EOC rounds. We will follow up until quarterly 

monitors reflect that the actions have been effective. 

Recommendation 9 We recommended that the VISN Director ensure that the 

Medical Center Director requires that infection control 

policies, practices, and training comply with current VHA 

policy and with CDC and OSHA guidelines. 

The VISN and Medical Center Directors agreed with our 

findings and recommendation and provided acceptable 

improvement plans. EMS staff have completed the 

appropriate training, and infection control policies have 

been updated to comply with VHA policy and with CDC and 

OSHA guidelines. We will follow up until quarterly monitors 

reflect that the actions have been effective. 

Medication 

Management 

The purpose of this review was to evaluate whether the 

medical center had developed effective and safe medication 

management practices. A safe medication management 

system includes medication ordering, administering, and 

monitoring. We reviewed selected medication management 

processes on an inpatient medical ward (3B), on the 

intensive care unit, and in the CLC. 

We found that the medical center had a designated Bar 

Code Medication Administration coordinator who 

appropriately identified and addressed problems. In 

general, pharmacy staff completed monthly medication 

reviews for CLC patients. However, we identified the 

following area that needed improvement. 

Pain Medication Effectiveness Documentation. Local policy 

requires that nurses assess and document the 

effectiveness of PRN (as needed) pain medication within 

240 minutes after administration. We reviewed the medical 

records of 10 patients who received a total of 49 doses of 

pain medications during the timeframe June 7–19, 2009. 

Only 33 (67 percent) of the 49 doses had effectiveness 

documented within the timeframe specified by local policy. 

Managers agreed that timely assessment and 

documentation of pain medication effectiveness are 

important. 

Recommendation 10 We recommended that the VISN Director ensure that the 

Medical Center Director requires that nurses consistently 

VA Office of Inspector General 16 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

VA Office of Inspector General 17 

assess and document PRN pain medication effectiveness 

within the timeframe specified by local policy. 

The VISN and Medical Center Directors agreed with our 

finding and recommendation and provided acceptable 

improvement plans. PRN pain medication effectiveness is 

now tracked and reported to the Nursing Service 

Committee, and continuous medical record reviews have 

been established to monitor compliance. We will follow up 

until quarterly monitors reflect that the actions have been 

effective. 

Review Activities Without Recommendations 

Coordination of 

Care 

The purpose of this review was to evaluate whether 

inpatient intra-facility transfers and discharges were 

coordinated appropriately over the continuum of care and 

met VHA and external accrediting body requirements. 

Coordinated transfers and discharges are essential to an 

integrated, ongoing care process and optimal patient 

outcomes. 

We reviewed the documentation for 10 intra-facility transfers 

that occurred during the timeframe May 20–31, 2009, and 

determined that all cases were managed appropriately. We 

found transfer notes from sending to receiving units and 

documentation that nursing assessments were performed 

by the receiving units within established timeframes. 

We reviewed the medical records of 10 discharged patients 

and found that that all patients received appropriate written 

discharge instructions. We also found documentation that 

the patients understood those instructions. We made no 

recommendations. 

VHA Satisfaction Surveys 

VHA has identified patient and employee satisfaction scores as significant indicators of 

facility performance. Patients are surveyed monthly, and data are summarized 

quarterly. Figure 1 on the next page shows the medical center’s and VISN’s overall 

inpatient satisfaction scores for quarters 1 and 2 of FY 2009.13 The target score is 

noted on the graph. 

 

13 Due to technical difficulties with VHA’s outpatient survey data, no outpatient satisfaction scores are available for 

quarters 1 and 2 of FY 2009. 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

40

45

50

55

60

65

70

75

80

85

90

Qtr 1 (FY 09) Qtr 2 (FY 09)

Percent Reporting Overall Quality as Very Good or 

Excellent

Quarter Reported

Facility

VISN

INPATIENT OVERALL QUALITY

BY QUARTER

Meets

Target

Figure 1:

Employees are surveyed annually. Figure 2 below shows the medical center’s overall 

employee scores for 2007, 2008, and 2009. Since no target scores have been 

designated for employee satisfaction, VISN and national scores are included for 

comparison. 

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

2007 2008 2009

Facility

VISN

National

VA ALL EMPLOYEE SURVEY

OVERALL SATISFACTION Figure 2:

LEVEL OF SATISFACTION 

VA Office of Inspector General 18 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 19 

Department of 

Veterans Affairs Memorandum 

Date: October 27, 2009 

From: Director, VA Heartland Network (10N15) 

Subject: Combined Assessment Program Review of the Marion 

VA Medical Center, Marion, Illinois 

To: Director, Atlanta Office of Healthcare Inspections (54AT) 

Director, Management Review Service (10B5) 

Please accept the revised response to the Combined Assessment 

Program Review of the Marion VA Medical Center, Marion, Illinois, 

previously submitted to your office on October 15, 2009. 

 (original signed by:)

JAMES R. FLOYD, FACHE 

Director, VA Heartland Network 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

Appendix B 

Medical Center Director Comments 

VA Office of Inspector General 20 

Department of 

Veterans Affairs Memorandum 

Date: October 26, 2009 

From: Director, Marion VA Medical Center (657A5/00) 

Subject: Combined Assessment Program Review of the Marion 

VA Medical Center, Marion, Illinois 

To: Director, VA Heartland Network (10N15) 

I concur with the findings from the OIG CAP visit conducted 

August 17–21, 2009. We recognize the progress that has been made, 

and both acknowledge and appreciate the opportunity to improve care for 

the nation’s Veterans. The attached responses with action plans, as 

appropriate, for the recommendations are being resubmitted for your 

consideration. 

At the time of this review, the VA Medical Center Marion, Illinois, had 

programs in all areas identified as needing improvement: Quality 

Management Oversight and Reporting; Adverse Event Disclosure; Medical 

Records Review; Mortality Review; Operative and Other Invasive 

Procedures; Patient Safety; Peer Review; Resuscitation and Its 

Outcomes; System Redesign/Patient Flow; Utilization Management; 

Physician Privileging; Environment of Care Rounds; NFPA Requirements; 

Infection Control Policies; Documentation of PRN Pain Medication 

Effectiveness. 

VA Medical Center management had identified areas of improvement in 

most of these areas and was taking actions to strengthen these programs. 

We concur that these programs could be further enhanced through 

additional improvements. 

(original signed by:)

WARREN E. HILL 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

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 an overall redesign of the QM 

oversight and reporting structure. 

Concur Completion Date: Complete 

The VA Medical Center Marion, Illinois, had a functioning quality 

management structure complete with reporting and oversight 

responsibilities in place at the time of this review. Opportunities for 

improvement in this structure had been identified by VA Medical Center 

management and were being implemented. We concur that these existing 

oversight and reporting structures could be strengthened through 

additional improvements. As a result of this review, the organization’s 

governance structure has been redesigned, approved, and published with 

special attention to the four repeat areas. Committee data analysis and 

reporting have been intensified under this revised structure, and a new 

Quality Management (QM) organization chart is in place congruent with 

Veterans Health Administration (VHA) Directive 2009-043, Quality 

Management Systems. 

Recommendation 2. We recommended that the VISN Director ensure 

that the Medical Center Director requires the QM program to comply with 

VHA and local policies pertaining to: 

• Adverse Event Disclosure. 

Concur Completion Date: 10/26/09 

The VA Medical Center Marion, Illinois, had an adverse event disclosure 

process at the time of this review. Opportunities for improvement in this 

process had been identified by VA Medical Center management and were 

being implemented. We concur that this process could be strengthened 

through additional improvements. As a result of this review, the clinical 

and institutional disclosure processes and the Peer Review Committee 

Policy have been revised to be congruent with VHA Directive 2008-004. 

Trigger points are integrated into the clinical screen and peer review 

process to consider the need for disclosure. Clinical reviewers, committee 

members and medical staff have been trained. Peer review case load is 

VA Office of Inspector General 21 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

tracked through the Risk Management process. Outcome information is 

included in the monthly risk management report to the Clinical Executive 

Board. 

• Medical Record Review. 

Concur Completion Date: Complete 

The VA Medical Center Marion, Illinois, had a functioning medical records 

review process complete with committee reporting and oversight 

responsibilities in place at the time of this review. We concur that the 

existing medical records review processes could be strengthened through 

additional improvements. As a result of this review, the Medical Records 

Committee process has been modified so that data collection, analysis, 

and results tracking are reported through the governance structure to the 

Clinical Executive Board. Additional improvements include a physician 

appointed as chair of the Medical Records Committee, point of care record 

reviews, and reeducation of staff about these policy changes. The Copy 

and Paste Policy has also been updated and disseminated throughout the 

organization. 

• Mortality Review. 

Concur Completion Date: Complete 

The VA Medical Center Marion, Illinois, had a mortality review process in 

place at the time of this review, and no patients had been identified as 

being at risk. We concur that the mortality review processes could be 

strengthened through additional critical analysis of all mortality data. 

Additionally, the standard operating procedure (SOP) and screening tool 

for mortality assessment have been updated to include all criteria from 

VHA Directive 2005-056, and QM staff has been trained. An analysis of 

mortality records has been performed to verify facility data. Monthly 

reporting including analysis of mortality trends to the Clinical Executive 

Board is congruent with VHA Directive 2005-056. 

• Operative and Other Invasive Procedures. 

Concur Completion Date: 11/2/09 

The VA Medical Center Marion, Illinois, had a functioning Operative and 

Invasive Procedures review process in place at the time of this review. 

We concur that the existing Operative and Invasive Procedures review 

process could be strengthened through additional improvements. As a 

result of this review, the Surgical Quality Assurance Committee (SQAC) 

will submit monthly moderate sedation trends and analyses to the Clinical 

VA Office of Inspector General 22 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

Executive Board. Use of a site-specific grid that identifies all areas for 

moderate sedation has been developed and is in use. Staff that is 

responsible for completing the grid has been educated on its use. 

• Patient Safety. 

Concur Completion Date: Complete 

The VA Medical Center Marion, Illinois, had a Patient Safety program in 

place at the time of this review. Although no patients were identified as 

being at risk, we concur that the existing patient safety program could be 

strengthened through additional improvements. As a result of this review, 

patient safety programs have been integrated into the governance 

structure with regular monthly and annual reporting. Root Cause 

Analyses are presented to executive leadership, discussed in the Patient 

Safety Committee, and tracked to completion. Issues related to patient 

safety, which are identified through the peer review process, are 

documented and sent to Patient Safety. The Patient Safety Manager is a 

member of the Peer Review Committee. 

• Peer Review. 

Concur Completion Date: 10/30/09 

The VA Medical Center Marion, Illinois, had a functioning peer review 

process in place at the time of this review, and no patients were identified 

as being at risk. We concur that the peer review processes could be 

strengthened through additional improvements. As a result of this review, 

a plan for timely peer review and reducing the backlog of cases has been 

established and includes internal and external peer reviewers. A revised 

peer review tracking tool is being used to accurately track case load. 

Quarterly reports on timeliness will be reported through the governance 

structure to the Clinical Executive Board and Joint Leadership Council. 

Issues related to patient safety, which are identified through the peer 

review process, are documented and sent to Patient Safety. The Patient 

Safety Manager is a member of the Peer Review Committee. In addition, 

the process of integrating the cases from the Operative and Invasive Case 

Review Committee into the peer review process has been clarified. The 

19 of the 27 cases from the February 2009 meeting have been closed. 

Eight cases are in process. 

• Resuscitation and Its Outcomes. 

Concur Completion Date: 10/30/09 

The majority of Marion, Illinois, VA Medical Center employees who 

needed Advanced Cardiac Life Support (ACLS) and Basic Life Support 

VA Office of Inspector General 23 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

(BLS) training to perform their duties were trained on resuscitation and its 

outcomes even though the medical center’s policy did not identify all those 

that were required to have this training. Employees identified as needing 

training were in the Police Service. We concur that the existing medical 

center policy and tracking tool could be strengthened through additional 

improvements. As a result of this review, the Cardio-Pulmonary 

Resuscitation Procedures policy has been revised and is in compliance 

with VHA Directives 2008-008 and 2008-063. Staff requiring Advanced 

Cardiac Life Support (ACLS) and Basic Life Support (BLS) is being trained 

and a tracking process established to assure certification currency for all 

applicable staff with reporting to the Critical Care Committee and Clinical 

Executive Board. 

• System Redesign/Patient Flow. 

Concur Completion Date: Complete 

The VA Medical Center Marion, Illinois, had a System Redesign Program 

at the time of this review. Opportunities for improvement in this program 

had been identified by VA Medical Center management and were being 

evaluated. We concur that the existing System Redesign program could 

be strengthened through additional improvements. As a result of this 

review, the System Redesign Program has been reviewed and 

incorporated into the Performance Improvement Program policy with 

quarterly reports to the Quality Executive Board to monitor effectiveness of 

actions taken. 

• Utilization Management. 

Concur Completion Date: 10/30/09 

The VA Medical Center Marion, Illinois, had a functioning Utilization 

Management program at the time of this review. Opportunities for 

improvement in this program had been identified by VA Medical Center 

management and were being implemented. We concur that this program 

could be strengthened through additional improvements. As a result of 

this review, the Utilization Management Committee policy is being revised 

to provide oversight, reporting and tracking of the patient flow functions, 

patient flow processes and improvements, and analysis with reporting to 

the Quality Executive Board. 

Recommendation 3. We recommended that the VISN Director ensure 

that the Medical Center Director requires full integration of the patient 

safety program throughout the medical center. 

Concur Completion Date: Complete 

VA Office of Inspector General 24 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

The VA Medical Center Marion, Illinois, had a Patient Safety program in 

place at the time of this review. Although no patients were identified as 

being at risk, we concur that the existing patient safety program could be 

strengthened through additional improvements. As a result of this review, 

the Patient Safety Program has been integrated into the governance 

structure, e.g., Quality Executive Board, Clinical Executive Board, and the 

Joint Leadership Council, with regular monthly and annual reporting. An 

electronic SharePoint site has been established to facilitate integration 

where Patient Safety and Quality Management staff have access to 

documented data, information, and analyses. 

Recommendation 4. We recommended that the VISN Director ensure 

that the Medical Center Director requires routine collection, trending, 

analysis, and reporting of QM data. 

Concur Completion Date: Complete 

The VA Medical Center Marion, Illinois, had a functioning quality 

management structure complete with reporting and oversight 

responsibilities in place at the time of this review. Opportunities for 

improvement in the data analysis and reporting structure had been 

identified by VA Medical Center management and were being 

implemented. We concur that the existing reporting structure could be 

strengthened through additional improvements. As a result of this review, 

the Quality Management reporting structure has been redefined and 

information has been disseminated to staff. Quality Management staff has 

received further training in data analysis and the use of data management 

tools to enhance their ability to analyze data and assist other departments. 

The “Council, Boards, and Committees” policy has been updated, which 

includes a standardized template for meeting minutes using the 

Conclusions, Recommendations, Actions, and Evaluation (CRAE) format. 

Recommendation 5. We recommended that the VISN Director ensure 

that the Medical Center Director requires that corrective actions relative to 

QM areas are evaluated for effectiveness and that outcomes are 

measured. 

Concur Completion Date: 11/30/09 

The VA Medical Center Marion, Illinois, had a quality management 

program in place at the time of this review. Opportunities for improvement 

in program had been identified by VA Medical Center management and 

were being implemented. We concur that the existing effectiveness and 

outcome measurements could be strengthened through additional 

improvements. As a result of this review, the medical center continues to 

strengthen the Quality Management program. Evaluation of effectiveness 

will be a standard agenda item for governance bodies such as the Quality 

VA Office of Inspector General 25 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

Executive Board, Clinical Executive Board, and the Joint Leadership 

Council. Quality Management experts provided training to key staff on 

how to collect, review, and analyze data using statistical and analytical 

tools for effective decision-making. Furthermore, the aforementioned 

collegial relationships with Quality Management experts will be sustained 

to evaluate and provide feedback to the Quality Executive Board, Clinical 

Executive Board, and the Joint Leadership Council on the effectiveness of 

the Quality Management program. 

Recommendation 6. We recommended that the VISN Director ensure 

that the Medical Center Director requires that physician privileging 

processes comply with VHA requirements. 

Concur Completion Date: 10/30/09 

The VA Medical Center Marion, Illinois, had a functioning privileging 

program complete with reporting and oversight responsibilities in place at 

the time of this review. Opportunities for improvement in these areas had 

been identified by VA Medical Center management and were being 

implemented. We concur that the existing privileging program could be 

strengthened through additional improvements. As a result of this review, 

Quality Management and Service Chiefs work collaboratively to develop 

sustainable improvements by providing current, reliable, specialty-specific 

monitoring information to confirm privilege competency in the Ongoing and 

Focused Professional Practice Evaluations. Regular recurring reports will 

be presented at the Professional Standards Board. The Professional 

Standards Board minutes will include detailed discussions of physicians’ 

performance data. 

A physician performance and provider profile library is used as a 

standardized process that provides clarity to the assessment of 

competency. A required training session on physician privileging 

processes for Professional Standards Board members, credentialing, and 

quality management staff is scheduled. An automated system is being 

pursued so that credentials and privileges are readily accessible to 

appropriate staff. 

Recommendation 7. We recommended that the VISN Director ensure 

that the Medical Center Director requires that deficiencies identified during 

EOC rounds are appropriately reported and that corrective actions are 

tracked through resolution. 

Concur Completion Date: Complete 

The VA Medical Center Marion, Illinois, performed environment of care 

rounds at the time of this review. Opportunities for improvement in this 

program and reporting process had been identified by VA Medical Center 

VA Office of Inspector General 26 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

management and were being implemented. We concur that environment 

of care rounds could be strengthened through additional improvements. 

As a result of this review, a process has been established to report 

environment of care findings through the Environment of Care Committee 

and governance structure to the Joint Leadership Council. A revised 

environment of care rounds tracking tool has been implemented. 

Implementation of an automated reporting tool is being pursued to 

facilitate tracking. 

Recommendation 8. We recommended that the VISN Director ensure 

that the Medical Center Director requires that all bathroom receptacles, 

storage areas, and corridors comply with NFPA requirements. 

Concur Completion Date: Complete 

Proper shelf height and items in hallways have been addressed and are 

monitored through environment of care rounds. Ground-fault 

circuit-interrupter (GFCI) protected receptacles have been installed in 

bathrooms according to the National Fire Protection Association’s (NFPA) 

National Electric Code. 

Recommendation 9. We recommended that the VISN Director ensure 

that the Medical Center Director requires that infection control policies, 

practices, and training comply with current VHA policy and with CDC and 

OSHA guidelines. 

Concur Completion Date: Complete 

The majority of Marion, Illinois, VA Medical Center employees who 

needed infection control training to perform their duties were trained. The 

Medical Center’s policies were not in compliance with VHA policies and 

CDC and OSHA guidelines. Employees identified as lacking training were 

in Environmental Management Service. We concur that the existing 

medical center policies could be strengthened through additional 

improvements. As a result of this review, Environmental Management 

Service (Housekeeping) staff have completed annual review of cleaning 

and disinfection procedures and OSHA Blood Borne Pathogen Rule. 

Infection Control policies have been updated and comply with VHA policy 

and CDC and OSHA guidelines. 

Recommendation 10. We recommended that the VISN Director ensure 

that the Medical Center Director requires that nurses consistently assess 

and document PRN pain medication effectiveness within the timeframe 

specified by local policy. 

Concur Completion Date: Complete 

VA Office of Inspector General 27 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

VA Office of Inspector General 28 

VA Medical Center Marion, Illinois, was tracking PRN medication 

effectiveness at the time of this review. We concur that documentation of 

PRN pain medication effectiveness could be strengthened. As a result of 

this review, PRN pain medication effectiveness is now both being tracked 

and reported to the Nursing Service Committee. Medical record reviews 

have been established to monitor compliance. 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

Appendix C 

VA Office of Inspector General 29 

OIG Contact and Staff Acknowledgments 

Contact Victoria Coates, Director 

Atlanta Office of Healthcare Inspections 

(404) 929-5962 

Contributors Toni Woodard, Team Leader 

Audrey Collins-Mack 

Melanie Cool 

Jennifer Kubiak 

Reba Ransom 

Susan Zarter 

Jim Werner, Office of Investigations 
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois 

Appendix D 

VA Office of Inspector General 30 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Heartland Network (10N15) 

Director, Marion VA Medical Center (657A5/00) 

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 J. Durbin 

U.S. House of Representatives: Jerry Costello, Brad Ellsworth, S. Brett Guthrie, 

John Shimkus, Ed Whitfield 

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