Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Alleged Management Decisions Impacting 

Patient Care and Work Environment 

Oscar G. Johnson VA Medical Center 

Iron Mountain, Michigan 

Report No. 09-02470-61 January 13, 2010

VA Office of Inspector General 

Washington, DC 20420 

 
 

 

 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 between 8:30AM and 4PM Eastern Time,

 Monday through Friday, excluding Federal holidays

 E-Mail: vaoighotline@va.gov 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

Contents 

Page 

Executive Summary .............................................................................................ii

Purpose ................................................................................................................. 1 

Background .......................................................................................................... 1 

Scope and Methodology ...................................................................................... 3 

Inspection Results ............................................................................................... 4 

Issue 1 Management Arrogance is Affecting Patient Care and Staff Morale Adversely 4 

Issue 2 Intimidation ....................................................................................................... 12

Issue 3 Emergency Room Issues ................................................................................... 13 

Issue 4 Inconsistent and Frequent Changes ................................................................... 15 

Conclusions ........................................................................................................ 17 

Comments ........................................................................................................... 18 

Appendixes

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

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

C. OIG Contact and Staff Acknowledgments ............................................................... 24

D. Report Distribution .................................................................................................. 25

VA Office of Inspector General i 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

Executive Summary 

At the request of Chairman Bob Filner, House Committee on Veterans’ Affairs, the 

Office of Inspector General, Office of Healthcare Inspections reviewed the validity of 

multiple allegations regarding decisions impacting patient care and work environment at 

the Oscar G. Johnson VA Medical Center in Iron Mountain, MI. 

Certain allegations related to human resources concerns; physician recruitment and pay, 

intimidation, and perceptions of preferential treatment were not addressed and were 

beyond the scope of an OHI review. The remaining allegations were grouped into the 

following themes, as presented by the complainant: 

• Management arrogance affects patient care and staff morale adversely. 

• Intimidation. 

• Emergency room issues. 

• Inconsistent and frequent changes. 

Three of the allegations resulted in recommendations to the Veterans Integrated Service 

Network and Medical Center Directors. We recommended that actions be taken to 

reduce the scanning backlog and establish a process to assure timely entry of significant 

information in patients’ electronic medical records. We recommended that managers 

initiate a review of registered nurse staffing to ensure coverage of the Emergency 

Department and Nursing Officer of the Day. We also recommended that the Medical 

Center Director communicates, orally and in writing, organizational changes to all 

employees and that administrative supervisory lines are clearly written and effected in 

official personnel actions. 

Management agreed with the findings and recommendations and provided acceptable 

improvement plans. We will follow up on the planned actions until they are completed. 

VA Office of Inspector General ii 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

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

SUBJECT: Healthcare Inspection – Alleged Management Decisions Impacting 

Patient Care and Work Environment, Oscar G. Johnson VA Medical 

Center, Iron Mountain, Michigan

Purpose 

The VA Office of Inspector General (OIG), Office of Healthcare Inspections (OHI) 

conducted an inspection at the Oscar G. Johnson VA Medical Center (the medical center) 

in Iron Mountain, Michigan. The inspection was initially at the request of Congressman 

Bob Filner, Chairman of the House Committee on Veterans’ Affairs and involves 

multiple allegations concerning the medical center management. The purpose of the 

inspection was to determine the validity of the allegations. 

Background 

Located in Iron Mountain, Michigan, the medical center is part of Veterans Integrated 

Service Network (VISN) 12 and provides primary and secondary level care through a 

broad range of inpatient and outpatient health care services. The medical center has 

17 hospital beds and 40 community living center (CLC) beds. Outpatient care is also 

provided at six community based outpatient clinics (CBOCs) in Hancock, Ironwood, 

Marquette, Menominee, and Sault Sainte Marie, MI, and in Rhinelander, WI. The 

medical center serves a veteran population of about 56,000 throughout 15 counties in 

Michigan and 8 counties in northeastern Wisconsin. 

The complainant provided multiple allegations with examples as part of a number of 

general themes as follows: 

1. Management arrogance affects patient care and staff morale adversely. Examples 

included: 

a. Removing paper charts from the CBOCs without proper planning and training 

of clinical providers and nursing staff. 

VA Office of Inspector General 1 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

VA Office of Inspector General 2 

b. Sudden closure of the intensive care unit (ICU) without providing clear reason 

or prior notification to staff or patients. 

c. Reopening the ICU after 3 months with significantly more staff and a decrease 

in beds from six to four. 

d. A Substance Abuse Treatment Unit (SATU) had been discussed multiple times 

in the past few years, funding was obtained, but this was never accomplished. 

e. Moving a dietitian into a hospitalist workroom in the CLC without courtesy 

notification to the hospitalists, provisions for an alternative work space, or area 

for storage of patient information. 

f. Stopping the printing of abnormal radiology reports in Primary Care without 

informing clinical providers. 

g. Institution of a “no cancellation policy” resulting in patients being evaluated by 

multiple providers, with no continuity of care. 

h. All responsibility for inpatient medication reconciliation is being placed on 

hospitalists, despite repeated requests for additional inpatient pharmacists. 

i. Placing all fee basis consults on “administrative hold” for several months while 

creating more obstacles to get these tests and important services to veterans. 

Only those patients who need the tests emergently are being approved, 

resulting in an unfair delay to veterans’ care. Specific consults mentioned 

include sleep apnea, electromyography (EMG),1

 cardiology, pulmonary, and 

chiropractic. 

j. Nurses were given overtime for completing influenza clinical reminders to 

improve the VA score and not patient care. 

k. Management’s belief that the hospitalist program is a failure, resulting in the 

potential decision to close inpatient services again. 

l. Replacement of Emergency On Duty (OD) list with back-up Medical Officer 

of the Day (MOD) list, even though Emergency OD list worked successfully 

for the past 15 years. 

m. Hundreds of patients are without an assigned primary care provider (PCP). 

n. Front door project called for 3-feet-wide doors, not accommodating wide 

wheelchairs as recommended by the Americans with Disabilities Act (ADA). 

2. Intimidation. Examples included: 

a. Physicians placed on back-up MOD call during approved vacation time. 

 

1

 A technique for evaluating and recording the activation signal of muscles. 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

b. Staff reluctant to complete the employee survey for fear of reprisal, as the 

employee can be easily identified with a specific identification number. 

c. A senior manager inquired if a provider of a specific culture was a member of 

the American Federation of Government Employees (AFGE) (commonly 

known as an employee union). 

3. Emergency Room (ER) Issues. Examples included: 

a. Built with no patient privacy. 

b. Lack of triage protocols. 

c. No estimated wait time for non-emergent and non-urgent problems. 

d. Permanently understaffed. 

e. Untrained nurses forced to work in the ER. 

f. Untrained providers forced to cover in the ER. 

g. Nurses required to perform clerical responsibilities, as administration was not 

able to provide a clerk for the ER. 

4. Inconsistent and Frequent Changes. Examples included: 

a. Primary Care reorganization has occurred twice every year for the last 2 years. 

b. Hospitalists’ tours of duty have changed multiple times in the last few months 

without informing involved providers. 

c. ER versus Urgent Care (UC). Treatment room changed from ER to UC and 

changed back again several times. The Chief of Staff informed that the 

treatment room has been an ER for the last few months, but the services are 

still billed as an UC. 

d. High turnover of administrators. The medical center is a “stepping stone and 

most of the Directors and Associate Directors stay for 3–4 years and then move 

on.” 

e. High turnover of providers from factors like location, climate, and work 

environment, leading to patients evaluated by multiple providers with limited 

continuity of care and several patients with no assigned provider. 

Scope and Methodology 

We conducted a preliminary site visit at the medical center on July 21, 2009, and 

completed our full onsite inspection August 18–21. We reviewed pertinent documents 

which included Veterans Health Administration (VHA) and medical center policies and 

procedures, Joint Commission standards, committee minutes, quality management 

documents, and selected administrative and related management documents. 

VA Office of Inspector General 3 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

Certain allegations presented by the complainant were beyond the scope of an OHI 

review. These allegations were related to human resources concerns, physician 

recruitment and pay, intimidation, and perceptions of preferential treatment, and would 

more appropriately be managed through other non-OIG entities. We focused our efforts 

on those allegations that were directly related to the quality of patient care and the work 

environment. 

We initially contacted the complainant by telephone and requested supportive 

documentation. We also interviewed the complainant while onsite and again requested 

that the complainant provide documentation to support and clarify the allegations. 

Further, we made a third request for documentation while onsite, as well as a fourth 

reminder during a telephone contact with the complainant after our onsite visit. The 

complainant provided the OHI team with a listing of individuals perceived as most 

knowledgeable regarding each allegation. We interviewed many of the recommended 

individuals and others per allegation. If we noted consistencies in interviews, we 

determined whether additional interviews were warranted for each allegation. During the 

course of this inspection, we interviewed VISN 12 and medical center senior managers 

and other clinical and administrative staff. 

We conducted the inspection in accordance with Quality Standards for Inspections

published by the President’s Council on Integrity and Efficiency.

Inspection Results 

Issue 1: Management Arrogance is Affecting Patient Care and Staff Morale 

Adversely 

Allegation (a): Removing paper charts from the CBOCs without proper planning and 

training of clinical providers and nursing staff.

We substantiated that a management decision was made to remove paper charts from the 

CBOCs. However, we did not substantiate that there was a lack of planning or training of 

clinical staff. Following an incident regarding a potential breach of sensitive patient 

information in June 2007, managers investigated the incident and provided an issue brief 

to VHA. One of the recommendations detailed in this investigation was for all medical 

records at the CBOC locations to be brought to the medical center’s main file room. A 

new process for scanning medical records was to be developed, in addition to a servicelevel agreement to ensure compliance. For those paper records, such as non-VA test 

results brought to the CBOC by a patient, the provider reviews the documents, 

determines if the documents should be scanned for inclusion in the medical record and 

notates this accordingly, and documents any pertinent information in the patient’s 

medical record. All CBOC locations have computers available for clinical staff to access 

patients’ electronic medical records through the computerized patient record system 

(CPRS). Additionally, the medical center recognized that reduction of paper records 

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Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

VA Office of Inspector General 5 

would increase patient safety, ensure privacy, and allow others immediate access to 

documents through CPRS. All clinical staff received training on CPRS use. In 

preparation for the CBOCs’ paper record transition, additional CPRS training was 

provided onsite. The medical center also instituted a process for CBOC staff to request 

copies of paper record extracts when needed. 

During interviews related to this allegation, we learned that the medical center had a 

significant backlog of approximately 160 inches of documentation waiting for scanning. 

Results are prioritized, and the high priority documents are scanned first, with computer 

view alerts sent to providers. Managers acknowledged that staffing issues have 

contributed to the backlog. 

Recommendation 1: We recommended that the VISN Director ensure that the Medical 

Center Director takes immediate steps to reduce the scanning backlog and establish a 

process to assure timely entry of significant information in patients’ electronic medical 

records. 

Allegation (b): Sudden closure of the ICU without providing clear reason or prior 

notification to staff or patients. 

We substantiated the allegation. Closure of the medical center’s ICU occurred over the 

2008 Labor Day holiday weekend and was mandated by the former VISN 12 Director 

following multiple reviews of inpatient services. Significant gaps were identified in the 

consistency of ICU care during weekends, holidays, evenings, and night tours of duty. 

There were a limited number of internal medicine providers, and the medical center had 

limited success in recruiting qualified physicians. It was also identified that the 

Emergency Department (ED)2

 physician was responsible for inpatient and ICU coverage, 

in addition to the ED, which was contrary to a mandate from the Deputy Undersecretary 

for Health for Operations and Management (DUSHOM). After ongoing strategic 

discussions with medical center leadership, the former VISN 12 Chief Medical Officer 

(CMO) recommended in a memorandum to the Medical Center Director through the 

former VISN 12 Director on September 2, 2008, “Temporary diversion of inpatient ICU 

care until such time a recruitment of a complete cadre of board certified appropriate 

hospitalists and an appropriate ICU Chief can be in place to ensure an appropriate level 

of physician coverage is available at all times.” The medical center maintained closure of 

the ICU until early January 2009. 

Managers acknowledged that the ICU closure was abrupt to staff. Notifications were 

provided to staff that were on duty on the Friday prior to the closure, and managers also 

telephoned staff to alert them of this directive and to provide further guidance. Managers 

also sent e-mail messages and further updates. 

 

2

 Emergency Department (ED) and Emergency Room are used interchangeably in this report. Both describe the 

same area. 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

VA Office of Inspector General 6 

Allegation (c): Reopening the ICU after 3 months with significantly more staff and a 

decrease in beds from six to four.

We did not substantiate that there was a significant increase in staff after the ICU 

reopened. Managers reported no increase in staffing upon the reopening of the ICU. 

Managers had taken steps to implement a hospitalist program, and aggressive recruitment 

of board certified internal medicine physicians was continuing. We compared 

information from the Gains and Losses Sheets3

 from dates prior to the closure with dates 

after the ICU reopened. The medical center reported five authorized beds (4 Medical 

ICU, and 1 Surgical ICU); the same as the operating beds, both prior to closure and after 

reopening. Managers reported that they were directed by the VISN to limit capacity to 

four patients when they reopened the ICU. 

Allegation (d): An SATU had been discussed multiple times in the past few years, 

funding was obtained, but this was never accomplished.

We did not substantiate the allegation. There was not a request or approval for a SATU. 

The medical center operated a Psychosocial Residential Rehabilitation Treatment 

Program (PRRTP) from 2000–2003. The program provided beds for general mental 

health, substance use disorders, and Post-Traumatic Stress Disorder care. The PRRTP 

was a 24-hour, 7-days per week program with veterans residing onsite. Analysis of the 

program effectiveness was conducted and found that the average number of veterans per 

full-time employee was low, the mental health veterans served by the PRRTP beds 

consumed approximately 30 percent of all mental health resources, and 16–20 percent of 

the veterans in the PRRTP were outpatients who commuted to the medical center for the 

program. 

On August 26, 2003, the medical center and VISN developed a proposal to close the 

PRRTP based on lack of demand locally to maintain a supportable program with enough 

patient involvement to maintain staff competencies and ensure patient safety. The 

PRRTP resources were devoted to intensive outpatient substance abuse services at the 

medical center and to purchase needed services close to the homes of addicted veterans. 

Additionally, collaborative efforts were established with the Milwaukee and Tomah VA 

facilities to provide residential treatment for Iron Mountain veterans as needed. 

An intensive outpatient substance abuse treatment program has been established at the 

medical center, needed services are provided in the community where veterans reside, 

and residential treatment is available at VA facilities within the network. 

During early 2008 there were discussions about reopening the PRRTP; however, this did 

not come to fruition due to funding and staffing to support the program. 

 

3

 A daily report generated to include patient admissions, transfers, discharges, and bed status. 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

Allegation (e): Moving a dietitian into a hospitalist workroom in the CLC without 

courtesy notification to the hospitalists, provisions for an alternative work space, or 

area for storage of patient information. 

We did not substantiate the allegation. A dietitian was temporarily relocated to the CLC 

for approximately 2 months pending a Primary Care Clinic office assignment. This 

dietitian was assigned to a vacant office, room 1144, which was designated as a shared 

CLC physician office. In addition to a hospitalist work space on the medical center’s 

fourth floor, hospitalists who rotated CLC rehabilitation patient coverage shared work 

space in another office that included two work stations with computers. This area was 

also used by the CLC’s nurse practitioner. Employees were not asked to move or 

inconvenienced by the temporary office assignment for the dietitian’s use. 

Allegation (f): Stopping the printing of abnormal radiology reports in Primary Care 

without informing the providers.

We substantiated that a management decision was made to discontinue manual printing 

of abnormal radiology reports. We could not substantiate or refute that providers were 

given ample notice regarding this change. The decision to stop printing the reports was 

made in 2007. The past practice was to manually print all radiology reports, including 

abnormal reports, and deliver them to the Primary Care Clinic. Nursing staff were 

required to sort and separate reports for delivery to individual providers. This process 

was time consuming and involved multiple personnel. Managers assessed the potential 

for compromise in patient safety due to missed abnormal reports and the potential for 

compromise in patient privacy due to the printed sensitive information. It was 

determined that the CPRS provider alert function would be more safe and secure than the 

printed method of notification. We were not able to confirm whether sufficient notice 

was provided to those clinical staff involved at the time this decision was made. 

However, staff interviewed reported that the provider alert function in CPRS is the most 

effective method for communicating abnormal results. 

Allegation (g): Institution of a “no cancellation policy” resulting in patients being 

evaluated by multiple providers, with no continuity of care.

We did not substantiate the allegation. In an effort to minimize patient cancellations and 

ensure continuity of care, the Chief of Staff instituted a policy whereby providers must 

schedule planned absences well in advance of the event. Medical center policy requires, 

“Providers should schedule planned absences for conferences and vacations as far in 

advance as possible so schedule changes can be made before [patient] appointments are 

actually scheduled.” Further, the policy requires providers to submit a clinic cancellation 

request more than 90 days in advance of the clinic date, routing the request through the 

Service Chief, if the request involves more than two dates. The provider and Service 

Chief collaborate to identify alternative times for patients to be seen or to identify staff to 

cover in the provider’s absence. The medical center also clarified expectations regarding 

VA Office of Inspector General 7 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

VA Office of Inspector General 8 

emergency cancellations, defined as less than 30 days and greater than 1 day prior to the 

clinic date, as well as emergency cancellations on the clinic date or day prior. 

Allegation (h): All responsibility for inpatient medication reconciliation is being placed 

on hospitalists, despite repeated requests for additional inpatient pharmacists.

We did not substantiate the allegation. Joint Commission’s National Patient Safety 

Goal 8 requires that patient medications are accurately and completely reconciled across 

the continuum of care. This goal includes the following standards: 

• A process exists for comparing the patient’s current medications with those 

ordered for the patient while under the care of the organization. 

• When a patient is referred to or transferred from one organization to another, the 

complete and reconciled list of medications is communicated to the next provider 

of service, and the communication is documented. Alternatively, when a patient 

leaves the organization’s care to go directly to his or her home, the complete and 

reconciled list of medications is provided to the patient’s known primary care 

provider, the original referring provider, or a known next provider of service. 

• When a patient leaves the organization’s care, a complete and reconciled list of the 

patient’s medications is provided directly to the patient and, as needed, the family, 

and the list is explained to the patient and/or family. 

• In settings where medications are used minimally, or prescribed for a short 

duration, modified medication reconciliation processes are performed. 

The Chief of Pharmacy Service acknowledged that medication reconciliation is a 

collaborative effort shared by clerks, nurses, pharmacists, and providers. Medical center 

policy states that providers have the ultimate responsibility for medication reconciliation. 

This policy tasks the Pharmacy and Therapeutics Committee with the responsibility for 

reviewing and evaluating medication reconciliation compliance, monitoring data 

regarding the process, and initiating corrective actions. A Medication Reconciliation 

Charter Team was established, and the team reports their progress during the medical 

center’s Quality Council meetings. Additionally, medication reconciliation successes and 

challenges are reported to the DUSHOM as part of VHA’s 5 Million Lives Campaign.4

 

One of the 12 interventions of this campaign is: “Prevent adverse drug events by 

reconciling patient medications at every transition point in care.” We reviewed the 

medical center’s report to the DUSHOM for quarters 1, 2, and 3 of fiscal year (FY) 2009. 

 

 

4

 Institute for Healthcare Improvement’s voluntary initiative promoting the adoption of 12 improvements in care that 

can save lives and reduce patient injuries. 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

VA Office of Inspector General 9 

Quarter 1 notable actions included: 

“Interdisciplinary involvement and new software has allowed the facility to meet 

the goal of providing medication education sheets to patients. This list has 

expanded to include medications from other VAs in addition to non-VA 

medications thus prevention errors of omission with admission and duplication 

between facilities. Planned Actions: Further review shows one locum tenens5

hospitalist needs additional education on both monitors as his discharges are 

reflected in the low numbers.” 

Quarter 2 notable actions included: 

 “Use of standardized list. Standard Operating Procedure for outpatient medication 

reconciliation. Revision of outpatient medication reconciliation statistics. 

Planned Actions: Additional training to Primary Care.” 

Quarter 3 notable actions included: 

 “Medication reconciliation template for Primary Care is being developed to 

standardize documentation, provide better reporting, and allow group to identify 

educational needs. Planned Actions: Template development and continued 

education to providers.” 

While the Chief of Pharmacy Service reported ongoing challenges in recruiting 

pharmacists to the Iron Mountain area, he noted that aggressive medication reconciliation 

efforts are in place and closely monitored. 

Allegation (i): Placing all fee basis consults on “administrative hold” for several 

months while creating more obstacles to get these tests and important services to 

veterans. Only those patients who need the tests emergently are being approved, 

resulting in an unfair delay to veterans’ care. Specific consults include sleep apnea, 

EMG, cardiology, pulmonary, and chiropractic.

We substantiated that there has been greater scrutiny of fee basis services as part of an 

effort to be fiscally responsible. The medical center has also reduced the need for some 

fee basis services based on successful recruitment of qualified specialists. During the 

12-month period prior to our onsite review, the medical center recruited professionals in 

cardiology, neurology (including EMG and sleep study), chiropractic, and general 

surgery. Senior managers reported that providing these services onsite by the recruited 

specialists was optimal. Emergent and urgent consults in all specialties continued to be 

referred to appropriate sources. For example, we asked the medical center to provide 

statistics for cardiology consults during the period January 1 to July 17, 2009. Twentytwo fee basis consults were processed at non-VA facilities. The Madison VA facility 

 

5

 Physicians who contract with the medical center, usually on a short-term basis. 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

processed 14 consults; while the Milwaukee VA facility processed 115 consults. 

Additionally, the medical center utilizes the Milwaukee VA facility for tele-pulmonary 

clinic services. Senior managers also evaluated the use of fee basis chiropractic care 

because they identified a significant number of non-service-connected veterans who were 

receiving these services. During the same period, 79 chiropractic care episodes were 

provided through fee basis. The Chief of Staff determined that patients who had been 

provided ongoing fee basis chiropractic care required reevaluation by physical therapy, 

with recommendations to either continue chiropractic care as appropriate, or change the 

treatment plan based on the assessment. The Chief of Staff also opted to not discontinue 

chiropractic care for those service-connected veterans who had been on this regime for a 

significant time. 

We requested a summary of patient complaints related to this change in chiropractic care 

from October 2008 until our onsite visit. The Patient Advocate logged four complaints 

from patients who had been receiving chiropractic care for some time; however, they 

were informed that they would be receiving a physical therapy evaluation. Additionally, 

the medical center had successfully recruited a chiropractor, so the medical center will be 

providing these services onsite once the provider is on duty. 

Allegation (j): Nurses were given overtime for completing influenza clinical reminders 

to improve the VA score and not patient care.

We substantiated the allegation that nurses were given overtime, but not to improve the 

VA score, but to ensure patients were given opportunities to receive influenza vaccines. 

The Associate Director for Patient Care Services informed us that overtime was never 

mandated, many nurses volunteered on-duty time to assist with a “flu campaign,” and 

very little overtime was used. VHA established FY 2009 performance measures for 

influenza vaccine immunizations for veterans in targeted age ranges. The performance 

measures are evidence-based measures to improve patient care, and these include target 

percentages as goals. The medical center established a “flu campaign” committee who 

developed informational flyers about flu and how to receive the vaccine. A form was 

also developed for patient use to report the receipt of a flu vaccine at a non-VA facility. 

The committee action plan included having an e-mail message sent to all nurses 

requesting volunteers with the goal to recruit one nurse per CBOC location. We 

interviewed nurse managers who reported that overtime was authorized for nurses who 

volunteered, however there was little overtime used. As a result of these efforts, the 

medical center exceeded the performance measure targets during quarters 3 and 4 of FY 

2009. 

Allegation (k): Management’s belief that the hospitalist program is a failure, resulting 

in the potential decision to close inpatient services again. 

We did not substantiate the allegation. We interviewed senior managers regarding the 

hospitalist program. Managers reported the hospitalist program as successful, and in fact, 

VA Office of Inspector General 10 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

VA Office of Inspector General 11 

purposeful decisions have been made to augment this program. As a result of an external 

site visit that focused on inpatient services, the former VISN 12 CMO suggested a 

number of actions to address the identified coverage issues for the inpatient care units and 

ICU. The CMO recommended in a September 2, 2008, memorandum to the Medical 

Center Director through the former VISN 12 Director the temporary diversion of 

inpatient ICU care until such time a recruitment of a complete cadre of board certified 

hospitalists and an ICU Chief was in place to ensure an appropriate level of physician 

coverage at all times. The CMO also detailed additional actions in a September 3, 2008, 

memorandum to the medical center’s Chief of Staff and Associate Director for Patient 

Care Services. The memorandum cited the inpatient hospital coverage, described as 

“recently changed to a hybrid hospitalist model.” The CMO recognized the increasing 

level of acuity of patients and the challenges in recruiting board certified internal 

medicine providers to the area. Three providers initially volunteered to take on the role 

of hospitalists, including two internal medicine physicians and one family practice 

physician. The CMO stated in the memorandum, “While the use of mid-level providers 

currently under recruitment is a potential solution given the acuity of inpatients currently 

receiving care, an expansion of the hospitalist program would be a necessary component 

of this plan.” The CMO also detailed problems with the current hospitalists providing 

coverage for the ED. Managers assessed that the hospitalists should take a role in ED 

coverage; however, the DUSHOM guidance6

 requires that this function only be provided 

by dedicated physicians, not mid-level providers, such as nurse practitioners or physician 

assistants. 

Allegation (l): Replacement of Emergency OD list with back-up MOD list even though 

Emergency OD list worked successfully for the past 15 years. 

We substantiated that managers made a decision to change the way emergency back-up 

was managed. The Chief of Staff reported that the medical center previously maintained 

a listing of providers for call back during emergencies, such as occasions when a provider 

cannot report to duty due to illness. The procedure was for the Administrative Officer of 

the Day (AOD) to start at the top of the list, continuing to work down the list until 

someone agreed to come in. To ensure patient safety, the Chief of Staff instituted a fixed 

call back schedule. Providers are now assigned on call dates, with the expectation to be 

reachable by phone and able to report to the medical center within 1 hour of receiving the 

call. The Chief of Staff also allowed for providers to trade on call duty if their scheduled 

date was problematic. 

Allegation (m): Hundreds of patients are without an assigned PCP. 

We substantiated the allegation. Managers acknowledged that there has been turnover in 

providers resulting in patients who may not have yet been assigned a new provider. 

 

6

 DUSHOM memorandum to Network Directors, “Clarification of Provider Staffing Requirements for Emergency 

Departments and Urgent Care Clinics in VHA,” April 18, 2008. 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

Although all of the patients were receiving ongoing care, at the time of our onsite visit, 

there were approximately 257 patients who did not have an assigned PCP. Additionally, 

the medical center has supplemented staffing through the use of locum tenens 

contractors, although the contracts may be for only 3–6 months at a time. The medical 

center established a panel size of 1,200 patients for full-time physicians and 900 patients 

for full-time mid-level providers. The medical center was initiating a process to notify 

those patients whose provider was no longer there and to notify them of their new 

provider. 

Allegation (n): Front door project called for 3-feet-wide doors, not accommodating 

wide wheelchairs as recommended by the ADA.

We did not substantiate the allegation. Section 404.2.3 of the ADA requires that door 

openings shall provide a clear width of 32 inches (815 mm) minimum. The front door 

project began December 22 and concluded on December 31, 2008. A standard 36-inch 

swinging door with manual push button operation was installed. The doors were 

designed to be compliant with all applicable codes. 

In early 2009, complaints surfaced that patients with wide wheelchairs had difficulty 

using the entrance. The medical center contacted the VA’s contracting officer and 

requested additional funding to modify the doors. The original contracted company was 

contacted to remove the installed 36-inch doors and replace them with 48-inch doors. 

The second door installation project began May 1 and concluded May 6, 2009. The 

original 36-inch doors were retained by the medical center for use in a future project. 

Issue 2: Intimidation 

Allegation (a): Physicians placed on back-up MOD call during approved vacation 

time.

We could not substantiate or refute the allegation. We interviewed the employee 

responsible for creating the provider schedules. The employee described challenges in 

scheduling, especially ensuring appropriate coverage around planned absences. For 

example, 17 changes were made to the August 2009 schedule prior to it being posted. 

The Chief of Staff reported that one provider alerted him that they were scheduled for 

extra on-call days. This was identified as an error and corrected. However, we were 

unable to identify a specific provider whose schedule was in error. Managers’ intent is to 

schedule providers fairly and equitably and to correct errors when they are discovered. 

Allegation (b): Staff reluctant to complete the employee survey for fear of reprisal, as 

the employee can be easily identified with a specific identification number. 

We did not substantiate the allegation. We interviewed managers and employees most 

knowledgeable about the All Employee Survey to determine if survey responses could be 

linked to an individual. It was confirmed that this was not possible. Employees in 

VA Office of Inspector General 12 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

services with 10 employees or less were grouped with other smaller services. The 

medical center’s employee response rate has been tracked. In 2007, there was a 

91 percent response rate. Response rates for 2008 and 2009 were 79 percent and 83 

percent respectively. Managers have taken appropriate steps to identify areas for 

improvement based on survey responses. 

Allegation (c): A senior manager inquired if a provider of a specific culture was a 

member of the AFGE. 

We could not substantiate or refute the allegation. We conducted interviews with a 

significant number of employees who were members of the local AFGE, as well as those 

who were not. None of the individuals interviewed reported ever personally hearing or 

having others relay information about inquiries made regarding whether or not any 

particular provider was an AFGE member. Senior managers are generally not aware of 

those employees who are AFGE members, unless those employees are involved in an 

action where there is AFGE presence. 

Issue 3: Emergency Room Issues 

Allegation (a): Built with no patient privacy.

We did not substantiate the allegation. The ED has five bays separated by walls and a 

privacy curtain in front of each. A total of six beds are utilized in the ED, and one has 

been designated to accommodate female veterans. Staff told us they maintain patient 

privacy by talking in a low volume and keeping privacy curtains closed. We visited this 

area several times during the day and observed patients and staff. We did not find visual 

or auditory privacy issues. Privacy curtains were in use as needed, and staff spoke 

quietly while discussing medical treatment and care. 

Allegation (b): Lack of triage protocols.

We did not substantiate the allegation. Patients presenting to the ED for treatment are 

triaged by a registered nurse (RN) who utilizes the Emergency Severity Index (ESI). The 

ESI has 5 levels which identifies the process of how patient care will be delivered. Level 

1 is emergent; level 2 is urgent; level 3 is acute, level 4 is routine, and level 5 is nonurgent. According to medical center policy, patients triaged at levels 4 or 5 will be seen 

by a provider with the most immediate availability in Primary Care. If the patient does 

not have an assigned PCP or their PCP is stationed at a CBOC, they will be seen in a 

Primary Care Clinic with open appointments or availability due to patients who did not 

show for scheduled appointments. At the time of our inspection, a patient presenting to 

the ER enters an unstaffed room where there is signage directing the patient to pick up 

the telephone for assistance. Staff noted that at times patients do not call, but prefer to 

wait for a staff member to enter the room. The new ED manager had assessed patient 

VA Office of Inspector General 13 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

flow and identified this as problematic. Process changes were already underway at the 

time of our inspection. 

Allegation (c): No estimated wait time for non-emergent and non-urgent problems.

We did not substantiate the allegation. Managers have studied wait times for ED 

patients. The following table shows ED patient volume and wait times. 

Date Number of Patients 

Presenting to the ED 

Number of Patients 

Whose Wait Extended 

Beyond 6 Hours 

5/1/07–4/30/08 3,560 22 

5/1/08–4/30/09 3,343 21 

5/1/09–6/30/09 667 4 

Allegation (d): Permanently understaffed nurses.

We did not substantiate the allegation; however, we identified that the RN covering the 

ED during weekends, holidays, evenings, and nights also has a collateral duty as Nursing 

Officer of the Day (NOD). The ED is typically staffed Monday through Friday with 2 

RNs on the day shift, 1 RN on the evening shift, and 1 RN on the night shift. Weekend 

and holiday coverage generally consists of 1 RN per shift. If additional coverage is 

needed, RNs from the ICU or acute care unit may be requested to assist in the ED. NOD 

duties involve other administrative functions that may require the RN to leave the 

immediate ED area. This may result in a situation where there is no RN availability 

when a critical need arises in the ED. 

Recommendation 2: We recommended that the VISN Director ensure that the Medical 

Center Director requires a review of RN staffing to ensure proper coverage of the ED at 

all times as well as staffing to support NOD duties. 

Allegation (e): Untrained nurses forced to work in the ER.

We did not substantiate the allegation. RNs are assigned to Primary Care Service and 

complete an ED rotation every 8–9 weeks. We reviewed vacancy announcements for 

Primary Care RN positions, and these announcements include the expectation of 

providing coverage in the ED. RNs are orientated to the ED, and this training is 

documented. New RNs are also partnered with experienced staff. RN competency is 

assessed annually and includes duties that are consistent with RNs working in critical 

care. All RNs who work in the ED are required to maintain Advanced Cardiac Life 

VA Office of Inspector General 14 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

Support (ACLS) certification. Due to the medical center’s generally low patient volume, 

low acuity level, and non-acceptance of trauma cases, management recognized the need 

for additional training for staff to maintain critical care/ED-level competencies. 

Managers instituted staff rotation at the North Chicago VA Medical Center ED, 

participation in a local trauma nurse core curriculum, and telemetry training coordinated 

by an ICU RN. 

Allegation (f): Untrained providers forced to cover in the ER. 

We did not substantiate the allegation. VHA requires that a dedicated physician must be 

present and available at all times in the ED. The physician should have no other 

responsibilities outside of the ED. When the medical center instituted the hospitalist 

program, two internal medicine physicians and one family practice physician volunteered 

for this role. Due to limited physician staffing, the Chief of Staff required that the 

hospitalists assume ED coverage, among other patient care assignments within the 

medical center. The medical center recognized they were not in compliance with VHA 

requirements to have a dedicated physician in the ED at all times. This has been 

corrected, and physician coverage has also been augmented as a result of recent 

successful recruitment efforts. Physicians who cover in the ED are credentialed and 

privileged through the medical center’s Professional Standards Board. Physicians who 

cover the ED must maintain ACLS certification. 

Allegation (g): Nurses required to perform clerical responsibilities, as administration 

was not able to provide a clerk for the ER.

We substantiated the allegation. A clerk is not assigned to the ED. Management told us 

they would like to provide administrative support to every area of the medical center, but 

had to make difficult choices to prioritize the clerical resources. Nursing staff is 

responsible for performing clerical duties and answering the telephone during the day 

shift. The AOD is called to provide assistance during the weekends, holidays, and 

evening tours. 

Issue 4: Inconsistent and Frequent Changes 

Allegation (a): Primary Care reorganization has occurred twice every year for the last 

2 years. 

We substantiated the allegation. Managers confirm that there have been transitions in 

Primary Care leadership. In fact, we interviewed a manager who was unable to 

definitively say who his supervisor was. Employees interviewed reported that there have 

been many changes in the organization, and that the changes have not always been 

effectively communicated. Staff at all levels reported that there was a need for improved 

communication by senior managers. The Medical Center Director did inform us that he 

holds regularly scheduled VISN and Town Hall forums, and Director Staff, Quality 

VA Office of Inspector General 15 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

VA Office of Inspector General 16 

Council, and Clinical Executive Board meetings. There are many open invitational 

venues to keep employees apprised of new information. Additionally, information is 

posted on the medical center’s intranet homepage and email is sent to all employees 

regarding new initiatives and changes. Documents show that though invited, there is 

absent membership for labor/management employee representatives in multiple 

management meetings and standing committees. 

Recommendation 3. We recommended that the VISN Director ensure that the Medical 

Center Director communicates, orally and in writing, organizational changes to all 

employees and that administrative supervisory lines are clearly written and effected in 

official personnel actions.

Allegation (b): Hospitalists’ tour of duty has changed multiple times in the last few 

months without informing involved providers. 

We substantiated that there have been changes in the hospitalists’ tours of duty, but did 

not substantiate that these were made without proper notice. We interviewed providers 

and administrative staff who were knowledgeable of the changes. Staff reported the 

schedule changed many times and needed to be frequently checked to ensure tours of 

duty were not inadvertently missed. Providers were able to view the schedule 

electronically. 

Allegation (c): ER versus UC. Treatment room changed from ER to UC and changed 

back again several times. The Chief of Staff informed that treatment room has been 

ER for last few months, but the services are still billed as an UC.

We substantiated the allegation. VHA policy requires that in facilities having 

medical/surgical beds and an ICU, there is a dedicated unit to provide unscheduled access 

to emergency care each day, 24 hours a day.7

 During an external audit in 2000, it was 

determined that the medical center’s complexity level did not support having an ED. The 

ED was transitioned to an UC Clinic for 6 years. In late 2006, the medical center 

transitioned back to ED status. 

In 2008, the VISN conducted a review of the inpatient services and found that staff levels 

were not appropriate to support the ICU. Actions were implemented for the temporary 

diversion of inpatient ICU care until such time a recruitment of significant physicians 

occurred. During this time, the ED was reduced to an UC Clinic. 

In early 2009, appropriate staffing levels were obtained, and the UC Clinic was 

transitioned back to an ED. Specific billing codes are designated for care provided in the 

ED and UC Clinic. Administrative staff were responsible for converting the codes to 

reflect the level of care provided in the ED. 

 

7

 VHA Directive 2006–051, Standards for Nomenclature and Operations in VHA Facilities Emergency 

Departments, September 15, 2006. 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

Allegation (d): High turnover of Administrators. The medical center is a “stepping 

stone and most of the Directors and Associate Directors stay for 3–4 years and move 

on.”

We substantiated the allegation. Since 2000, the medical center has had three Directors, 

three Associate Directors, two Associate Directors for Nursing and Patient Care Services, 

and three Chiefs of Staff. Traditionally in VHA, senior managers might begin their 

careers in smaller or less complex medical facilities and later transfer to more complex 

facilities. Managers might also be asked by VHA officials to assume more responsible 

leadership roles and have the right to consider and pursue other career options. 

Allegation (e): High turnover of providers from factors like location, climate, and work 

environment, leading to patients evaluated by multiple providers with limited continuity 

of care and several patients with no assigned provider.

We substantiated the allegation. From July 1, 2008, to July 16, 2009, the medical center 

hired 25 physicians and 4 nurse practitioners. Managers told us that geographically, it is 

difficult to recruit providers to the area and once the providers are on staff, it is also 

difficult to retain them. Seven locum tenens contractors were approved on time-limited 

appointments. During this same period, 11 physicians left and the circumstances for their 

departure were as follows: 3 resigned for family reasons, 3 resigned for administrative 

matters, 1 resigned to seek another professional opportunity, 1 resigned due to new 

expectations of duties by the Chief of Staff, and 3 gave no reason. 

We were told that some patients were not assigned to providers due to the recruitment 

issues. Locum tenens were hired during the interim, and some patients were seen by 

multiple providers. As new providers were hired, patients who were unassigned were 

added to the panels. The new Chief of Staff conducted an inquiry and found that the 

panel size for existing providers was not being maximized. VA recommends that PCPs 

have a panel size of 1,200 patients and mid-level providers have 900 patients. 

Administrative changes were made to increase panel sizes to full capacity. At the time of 

our review, there were approximately 257 patients who were not assigned PCPs. 

Because of a shortage of providers and a lack of a group of consistent physicians, the 

patients received care but were seen by different providers. We were informed that there 

were between 200-300 patients that might not have had an assigned provider during the 3 

months prior to our onsite inspection. Various clinical and administrative staff were 

currently working on ensuring that all unassigned patients have assigned PCPs. This 

includes an action plan whereby staff are assigning patients based on provider panels, 

patient preferences, and notifying patients by mail. 

Conclusions 

Management made decisions to improve patient care in many areas, but changes were not 

always well received by others. While we did find some opportunities for improvement 

VA Office of Inspector General 17 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

VA Office of Inspector General 18 

as outlined in our recommendations, we did not conclude that management decisions 

negatively impacted patient care or the work environment. 

Comments 

The VISN and Medical Center Directors agreed with the findings and recommendations 

and provided acceptable corrective actions. (See Appendixes A and B, pages 19–23, for 

the full text of the Directors’ comments.) We will follow up on the planned actions until 

they are complete. 

 (original signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC

Appendix A 

VISN Director Comments 

VA Office of Inspector General 19 

Department of 

Veterans Affairs Memorandum

Date: December 15, 2009 

From: Director, VA Great Lakes Health Care Network (10N12) 

Subject: Healthcare Inspection – Alleged Management Decisions 

Impacting Patient Care and Work Environment, Oscar G. 

Johnson VA Medical Center, Iron Mountain, Michigan

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

1. VISN 12 is committed to a culture of continuous improvement via 

ongoing collaboration and transparent partnerships with external review 

bodies within VISN 12 medical centers. Beginning December of 2007, 

VISN 12 began a thorough onsite review of patient services at the 

Oscar G. Johnson VA Medical Center. Since that time, improvements 

and assistance have continued as evidenced by the following groups: 

a. VISN 12: March 2009, June/July 2009, September 2009 

b. VA/VHA: July 2008 (SOARS), September 2008 (LTCI) 

c. Joint Commission: April 2008 (mock review 2009 standards), 

March 2009 (triennial), June 2009 

d. Office of Inspector General: July 2009 (CAP) 

2. I have reviewed and concur with the recommendations of the Office of 

Inspector General. The Oscar G. Johnson VA Medical Center is 

proceeding with the completion of the following attached action plan. 

3. The professionalism and consultative manner demonstrated by your 

team during this review process was appreciated by all. 

JEFFREY A. MURAWSKY, M.D. 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC

Appendix B 

Medical Center Director Comments 

VA Office of Inspector General 20 

Department of 

Veterans Affairs Memorandum

Date: December 7, 2009 

From: Director, Oscar G. Johnson VA Medical Center (585/00) 

Subject: Healthcare Inspection – Alleged Management Decisions 

Impacting Patient Care and Work Environment, Oscar G. 

Johnson VA Medical Center, Iron Mountain, Michigan

To: Director, VA Great Lakes Health Care Network (10N12) 

I have reviewed the draft report of the Inspector General’s Healthcare 

Inspection regarding Alleged Management Decisions Impacting Patient 

Care and Work Environment at the Oscar G. Johnson VAMC. My 

responses are enclosed. 

 

 (original signed by:) 

MICHAEL J. MURPHY, FACHE 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC

Director’s 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’s report: 

OIG Recommendations

Recommendation 1. We recommended that the VISN Director ensure 

that the Medical Center Director takes immediate steps to reduce the 

scanning backlog and establish a process to assure timely entry of 

significant information in patients’ electronic medical records. 

Concur Target Completion Date: February 1, 2010 

The scanning backlog was decreased from 160 inches at time of the survey 

(August 18, 2009) to 8 inches as of November 20, 2009. This was 

accomplished by additional training of staff, including night shift staff 

during quiet period of their assigned night duties. Health techs have been 

added to the ED staff and will perform clerical and scanning duties. 

The following process has been established to insure timely entry 

information in the electronic medical records: The Health Information 

Medical Section (HIMS) Chief receives daily reports from the scanning 

staff as to the number of pages scanned. The numbers are reported to the 

Chief of Patient Administration Service (PAS) and monthly reports 

submitted to the Administrative Executive Board by the Chief of PAS. 

Recommendation 2. We recommended that the VISN Director ensure 

that the Medical Center Director requires a review of RN staffing to 

ensure proper coverage of the ED at all times as well as staffing to 

support NOD duties. 

Concur Completed 

Medical Center Leadership (Director) reviewed the RN staffing in the 

Emergency Department (ED) along with the Associate Director for Nursing 

and Patient Care Service. The total number of ED visits from 

November 24, 2008, to November 25, 2009, totaled 3,968. Of this total, 

2,919 were on the day tour, 850 on the evening tour, and 199 on the 

midnight tour. The average number of patients on the evening shift was 

1.46 and on midnights 0.53. Data was also collected to illustrate average 

VA Office of Inspector General 21 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC

VA Office of Inspector General 22 

numbers based on day of the week, weekday versus weekend, and average 

per month. Leadership is not aware of any situation where a critical need 

was not met due to the absence of the RN in the ED when functioning as 

the NOD. Staffing models at similar facilities have been reviewed along 

with Directive 2009-055, titled Staffing. Decisions on staffing levels are 

based on the recommendations in the Directive related to analysis, tracking, 

and trending of patient outcome and performance indicators. We concluded 

that our current staffing model allows us to provide safe high quality care to 

patients in the most efficient manner possible. 

Recommendation 3. We recommended that the VISN Director ensure that 

the Medical Center Director communicates, orally and in writing, 

organizational changes to all employees and that administrative supervisory 

lines are clearly written and effected in official personnel actions. 

Concur Target Completion Date: January 15, 2010 

Medical Center leadership routinely uses various modes to communicate 

with OGJVAMC employees; for example, quarterly Town Hall meetings, 

monthly Director’s Staff Meetings, weekly all-employee bulletin 

announcements, ongoing all-employee emails, postings on the OGJVAMC 

facility homepage, and Medical Center committee minutes. All these 

communication tools are used to communicate organizational changes and 

administrative supervisory lines to employees. Management will increase 

the scrutiny and oversight of the use of these modes of communication to 

ensure that critical information is disseminated widely throughout the 

organization. Management also offers two opportunities, manual 

(anonymous) and electronic, to submit employee suggestions or comments 

related to a wide variety of issues affecting Medical Center operations. 

Lastly, the Medical Center Director is about to launch a Director’s Blog 

which will specifically target communication of ongoing issues related to 

Medical Center operations while providing employees an opportunity to 

provide specific feedback to management related to these issues. Potential 

topics include performance, new initiatives, hot topics, customer service, 

and VA community events. We anticipate the blog will be fully operational 

by January 15, 2010. 

In response to some concerns related to communication identified via the 

All Employee Survey (AES) earlier this year, the Senior Management 

Team invited a National Center for Organizational Development (NCOD) 

team to perform an Organizational Assessment of the Medical Center. The 

assessment occurred during the last week of September. Part of the action 

plan resulting from the NCOD assessment is a very detailed all-employee 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC

VA Office of Inspector General 23 

briefing provided by the Medical Center Director that addresses many areas 

of concern identified by both the AES and NCOD Organizational 

Assessment. The briefings began on December 1, 2009; subsequent 

sessions were held on December 7, 10, 14, and 15. The final session is 

scheduled for December 16, 2009. Part of the briefing is a reminder that 

any employee can contact or forward to a member of the leadership team at 

any level, or to a member of the Performance Improvement staff, issues or 

concerns they might have. These concerns may be done anonymously. 

Suggestions, concerns, and questions are also able to be posted to the 

“Suggestion Box” on the homepage for a member of the Executive 

Leadership Team to answer within 1 week for those items that require a 

response. A suggestion box is also available at the elevator of the main 

entrance for patient, family, and staff use. In the spring of 2009, the 

Medical Center Director started a rotation of attendance to service level 

staffing meetings to share communications with staff on a personal level. 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Verena Briley-Hudson, MN, RN 

Director, Chicago Office of Healthcare Inspections 

(708) 202-2672 

Acknowledgments Lisa Barnes, MSW 

Judy Brown 

Paula Chapman, CTRS 

Roberta Thompson, MSW 

VA Office of Inspector General 24 
Alleged Management Decisions Impacting Patient Care and Work Environment, Oscar G. Johnson VAMC 

Appendix D 

VA Office of Inspector General 25 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Great Lakes Health Care Network (10N12) 

Director, Oscar G. Johnson VA Medical Center (585/00) 

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: Russell D. Feingold, Herb Kohl, Carl Levin, Debbie Stabenow 

U.S. House of Representatives: Steve Kagen, David Obey, Bart Stupak 

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