Department of Veterans Affairs 

Office of Inspector General 

Combined Assessment Program 

Review of the 

St. Louis VA Medical Center 

St. Louis, Missouri 

Report No. 06-02818-100 March 14, 2007

VA Office of Inspector General 

Washington, DC 20420 
Office of Inspector General 

Combined Assessment Program Reviews 

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 and benefits 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 St. Louis VA Medical Center, St. Louis, Missouri 

Contents 

Page 

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

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

Medical Center Profile..................................................................................................... 1

Objectives and Scope of the Combined Assessment Program Review........................... 1

Results of Review.................................................................................................3

Opportunities for Improvement ....................................................................................... 3

Cardiac Catheterization Laboratory Standards ............................................................ 3

Environment of Care .................................................................................................... 4

Quality Management.................................................................................................... 6

Survey of Healthcare Experiences of Patients ............................................................. 8

Moderate Sedation...................................................................................................... 10

Other Review Topics ..................................................................................................... 10

Breast Cancer Management ....................................................................................... 10

Community Based Outpatient Clinics........................................................................ 11

Contract Community Nursing Homes........................................................................ 12 

Diabetes and Atypical Antipsychotic Medications.................................................... 13

Appendixes .........................................................................................................15

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

B. Medical Center Director Comments ........................................................................ 16

C. OIG Contact and Staff Acknowledgments............................................................... 22

D. Report Distribution .................................................................................................. 23

VA Office of Inspector General 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

Executive Summary 

Introduction 

The Office of Inspector General (OIG) conducted a Combined Assessment Program 

(CAP) review of the St. Louis VA Medical Center (the medical center), St. Louis, MO, 

during the week of October 2–6, 2006. The purpose of the review was to evaluate 

selected operations, focusing on patient care administration and quality management 

(QM). During the review, we provided fraud and integrity awareness training to 292 

medical center employees. The medical center is part of Veterans Integrated Service 

Network (VISN) 15. 

Results of Review 

The CAP review focused on eight areas. The medical center complied with selected 

standards in the following four areas: 

• Breast Cancer Management. 

• Community Based Outpatient Clinics. 

• Contract Community Nursing Homes. 

• Diabetes and Atypical Antipsychotic Medications. 

We identified four areas that needed additional management attention. To improve 

operations, we made the following recommendations: 

• Strengthen cardiac catheterization laboratory processes. 

• Correct environment of care deficiencies. 

• Improve QM structure and processes. 

• Develop Survey of Health Experiences of Patients corrective action plans. 

In addition, we followed up on previous healthcare CAP recommendations from the OIG 

report Combined Assessment Program Review of the VA Medical Center, St. Louis, 

Missouri (Report No. 04-01893-148, June 2, 2005) and made a recommendation for a 

repeat finding for Moderate Sedation regarding the cardiopulmonary resuscitation 

training policy. 

This report was prepared under the direction of Ms. Virginia Solana, Director, and 

Ms. Dorothy Duncan, Associate Director, Kansas City Regional Office of Healthcare 

Inspections. 

VA Office of Inspector General i 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

Comments 

The VISN and Medical Center Directors agreed with the CAP review findings and 

provided acceptable improvement plans (see Appendixes A and B, pages 15–21, for the 

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

they are completed. 

(original signed by:)

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

 Assistant Inspector General for 

 Healthcare Inspections 

VA Office of Inspector General ii 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

Introduction 

Medical Center Profile 

Organization. The St. Louis VA Medical Center (the medical center) is a two-division, 

tertiary care facility. The John Cochran division is located in downtown St. Louis, and 

the Jefferson Barracks division is located in south St. Louis County. The medical center 

also has community based outpatient clinics (CBOCs) located in St. Charles, MO; 

Belleville, IL; and at the Missouri State Veterans Home in north St. Louis County. 

Additional CBOCs are jointly operated with other VA medical facilities in Effingham 

and Springfield, Illinois.

Programs. With 116 acute care beds, the John Cochran division provides acute medical 

and surgical programs with a wide range of specialty care. The Jefferson Barracks 

division provides primary care and has 102 acute care beds (70 psychiatry and 32 spinal 

cord injury), a 50-bed domiciliary, and a 71-bed nursing home. 

Affiliations and Research. The medical center has affiliations with St. Louis University 

School of Medicine and Washington University School of Medicine. The residency 

program supports 122 positions. In addition, the medical center has affiliations with 

schools of nursing, pharmacy, psychology, physician assistants, and social work in the St. 

Louis area. 

In fiscal year (FY) 2006, the medical center’s Research Service reported expenditures of 

approximately $13.3 million in support of basic biomedical, clinical, and health services 

research. As of August 2006, the medical center had nine VA-funded basic biomedical 

research programs and three VA cooperative studies. In total, 85 investigators directed 

174 active programs.

Resources. The medical center’s budget expenditures for FYs 2005 and 2006 were 

approximately $244 million and $250 million, respectively. Staffing for FY 2005 was 

1,907 full-time equivalent employees (FTE). Staffing for FY 2006 was 1,911 cumulative 

FTE, including 127 physician and 353 nurse FTE. 

Workload. The medical center treated 83,345 patients in FY 2005. The inpatient care 

workload totaled 9,053 discharges, and the average daily census, including nursing home 

patients, was 214.8. Outpatient workload totaled 467,954 visits for FY 2006. 

Objectives and Scope of the Combined Assessment Program Review 

Objectives. Combined Assessment Program (CAP) reviews are one element of the 

Office of Inspector General’s (OIG’s) efforts to ensure that our Nation’s veterans receive 

high quality VA health care and benefits services. The objectives of the CAP review are 

to: 

VA Office of Inspector General 1 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

• Conduct recurring evaluations of selected health care facility operations focusing on 

patient care administration and quality management (QM). 

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

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

activity to the OIG. 

Scope. We reviewed selected clinical and administrative activities to evaluate the 

effectiveness of patient care administration and QM. Patient care administration is the 

process of planning and delivering patient care. QM is the process of monitoring the 

quality of care to identify and correct harmful and potentially harmful practices and 

conditions. 

In performing the review, we inspected work areas; interviewed managers and 

employees; and reviewed clinical and administrative records. The review covered the 

following eight activities: 

Breast Cancer Management 

Cardiac Catheterization Laboratory 

Standards 

CBOCs 

Contract Community Nursing Homes 

(CNHs) 

Diabetes and Atypical Antipsychotic 

 Medications 

Environment of Care (EOC) 

QM 

Survey of Healthcare Experiences of 

 Patients (SHEP) 

The review covered facility operations for FYs 2005 and 2006 and was done in 

accordance with OIG standard operating procedures for CAP reviews. We also followed 

up on the healthcare recommendations from our prior CAP review of the medical center 

(Combined Assessment Program Review of the VA Medical Center, St. Louis, Missouri, 

Report No. 04-01893-148, June 2, 2005). 

During this review, we also presented fraud and integrity awareness briefings for 292 

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 summarize selected focused inspections and 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 Other 

Review Topics section have no reportable conditions. 

VA Office of Inspector General 2 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

Results of Review 

Opportunities for Improvement 

Cardiac Catheterization Laboratory Standards – Informed Consents, 

Physician Training, and the Quality Improvement Review Process 

Needed To Be Strengthened 

Conditions Needing Improvement. Informed consents needed to consistently include 

the name of the procedure performed, potential risks of the procedure, the names of 

clinicians performing the procedure, and signatures of witnesses. Physicians who 

performed cardiac catheterization procedures needed to complete cardiopulmonary 

resuscitation training. The cardiac catheterization laboratory needed to report quality 

improvement information to the designated oversight committee. 

The purpose of this review was to evaluate if cardiac catheterization laboratory processes 

were consistent with American College of Cardiology/Society for Cardiac Angiography 

and Interventions (ACC) standards. Cardiac catheterization is a specialty procedure used 

to diagnose defects in the heart chambers, valves, and blood vessels. If physicians 

identify a blockage, they may perform a procedure to open the blockage in the cardiac 

catheterization laboratory or send the patient for a surgical procedure. The ACC has 

reported a direct correlation between complications and volume of procedures performed. 

Medical center physicians performed an acceptable volume of procedures and had low 

complication rates. Cardiac surgery was readily available for patients who required it. 

We reviewed the medical records of 10 randomly selected patients to determine the 

quality of the informed consent process, outcomes of the cardiac catheterization 

procedures, and if applicable, availability of surgery. None of the 10 patients had 

complications or required surgery. However, improvements were needed in the informed 

consent process. 

Informed Consents. Veterans Health Administration (VHA) requires that all practitioners 

who participate in cardiac catheterization procedures must be identified on the informed 

consent. We reviewed procedure notes and informed consents to determine if the 

practitioners who performed the procedures were the same as those noted on the 

consents. Only one (10 percent) of the 10 consents was correctly completed in all 

required areas. Two (20 percent) of the 10 consents had a different practitioner listed 

than the person who actually performed the procedure. Other documentation that was 

incomplete or missing included names of the procedures, descriptions of the procedures 

in layman’s terms and without abbreviations, details of the procedures, risks, and 

witnessed signatures. 

VA Office of Inspector General 3 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

Cardiopulmonary Resuscitation Training. As part of the review to determine if 

physicians who performed cardiac catheterization procedures had appropriate 

credentialing and training, we noted that neither attending physician had current 

cardiopulmonary resuscitation (CPR) training in the Credentialing and Privileging (C&P) 

records. VHA requires that all clinically active staff have CPR training. 

Quality Improvement Review. The Joint Commission on Accreditation of Healthcare 

Organizations (JCAHO) and ACC standards require that cardiac catheterization 

laboratories collect performance data in order to trend and analyze results and, if 

necessary, make recommendations for improvement. Cardiac catheterization laboratory 

managers had raw data on complication rates but had not reported to the medical center 

committee responsible for operative and invasive procedures oversight. Cardiology was 

in the process of expanding services and increasing workload and agreed that tracking 

data quarterly and reporting to the committee would be beneficial. 

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

Center Director requires that: (a) clinicians meet all requirements for completing 

informed consents, (b) cardiac catheterization laboratory physicians receive CPR training 

or document CPR proficiency, and (c) the cardiac catheterization laboratory develop a 

quality improvement review process and report findings to the designated oversight 

committee on at least a quarterly basis. 

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

An electronic template has been developed which will ensure that all informed consent 

requirements are met. Documentation of CPR training for each of the cardiac 

catheterization laboratory physicians was obtained, and review of the documentation 

shows both physicians are current in their certification. The cardiac catheterization 

laboratory will develop a quality improvement process, and the results will be reported to 

the Medical Staff Performance Improvement (PI) Committee on at least a quarterly basis. 

The improvement actions are acceptable, and we will follow up on reported 

implementation actions to ensure they have been completed. 

Environment of Care – General Conditions Needed To Be Improved 

Conditions Needing Improvement. We observed general environmental concerns 

related to cleanliness and infection control, including ceiling air vents, window air 

conditioning units, window sills, linen storage, and refrigerator thermometers. 

VHA policy requires that patient care areas be clean, sanitary, and maintained to optimize 

patient safety and infection control. We conducted EOC inspections on inpatient units 

and outpatient areas at the John Cochran and Jefferson Barracks divisions. We randomly 

selected and inspected eight pieces of clinical equipment at the John Cochran division 

and six pieces at the Jefferson Barracks division. All equipment was clean with properly 

functioning alarms, and preventive maintenance checks were current. The medical 

VA Office of Inspector General 4 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

center was generally clean and safe. Managers corrected most conditions identified 

during our inspection. 

General Environmental Conditions. We inspected occupied and unoccupied patient 

rooms; bathrooms; medication and utility rooms; Supply, Processing, and Distribution 

(SPD); and outpatient clinic areas at both divisions. We observed environmental 

concerns related to cleanliness and infection control, including: 

• Ceiling air vents. We observed thick dust covering air vent openings in several 

patient rooms at the John Cochran division. During our visit, it appeared that ceiling 

air vents had not been cleaned for some time. The July 27, 2006, EOC rounds 

identified the problem, but there was no corrective action noted. Ceiling air vents 

must be cleaned regularly to prevent infection control issues. 

• Portable window air conditioning units. We found dirty filters in portable window air 

conditioning units in several patient rooms at the John Cochran division. The filters 

had not been changed and were covered with dust. Filters in portable window air 

conditioning units must be clean to reduce the chance of respiratory infection. 

Management agreed to replace the filters immediately. 

• Window sills. We found large amounts of dust on window sills in multiple patient 

rooms at the John Cochran division. The staff told us that the window sills are not 

routinely dusted during regular room cleaning. Window sills must be included in 

regular room cleaning to maintain a clean and safe patient care environment. 

• Linen storage. We found bags with clean isolation gowns stored on the floor at both 

divisions. Staff reported that the bags constantly slip off the linen carts and fall on the 

floor. VHA and JCAHO require that clean linen must be stored off the floor. Linen 

found or stored on the floor is considered contaminated and should not be used for 

patient care activities. Use of contaminated linen may be a potential source for the 

spread of infectious organisms. 

• Refrigerator thermometers. We found patient nourishment and staff refrigerators 

with missing thermometers, although temperature logs were present and current. 

Nurses reported that refrigerator thermometers were visible on the previous day but 

could not locate the thermometers during our visit. Patient nourishment and staff 

refrigerator temperatures must be monitored and recorded daily to prevent spoilage of 

food and nourishments. Management agreed to provide thermometers during our 

visit. 

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

Center Director requires that (a) ceiling air vents are routinely checked and cleaned; 

(b) filters in window air conditioning units are inspected quarterly during EOC rounds 

and changed as needed; (c) window sills are regularly cleaned; (d) all clean linen, 

including cloth bags used for isolation gowns, be secured and not stored on the floor; and 

VA Office of Inspector General 5 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

(e) all refrigerators are checked daily for the presence of thermometers and recorded 

temperatures. 

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

Ceiling air vents will be checked and cleaned on a daily basis. A quarterly maintenance 

schedule has been established to inspect window air conditioners. This process will be 

monitored during EOC rounds. Environmental Management Service (EMS) will dust 

window sills on a daily basis. Cloth bags containing isolation gowns are now hung on a 

hook on the wall of the linen closet. The log sheets for refrigerators have been revised to 

record the presence of thermometers and recorded temperatures on a daily basis. EOC 

will monitor the log sheets. The improvement actions are acceptable, and we will follow 

up on reported implementation actions to ensure they have been completed. 

Quality Management – Improve Structure, Analysis, Documentation, 

Implementation, and Reporting Processes 

Conditions Needing Improvement. Program managers needed to collect and analyze 

pertinent data in all areas required by VHA policy and JCAHO. JCAHO requires 

hospitals to analyze data for trends and make recommendations to improve care. The 

medical center needed to improve their processes in key program areas. 

QM Program Structure. The medical center had three committees designated for QM 

oversight: (1) the Executive Committee of the Medical Staff, (2) the PI Committee of the 

Medical Staff, and (3) the Quality and Performance Management Council (QPMC). 

Membership in the first two groups, the Executive Committee and PI Committee, was 

limited to physicians; and only physicians reviewed physician QM. According to the 

Quality and Performance Management Plan, the medical staff committees (the first two 

committees) were responsible for monitoring and approval of medical records, pharmacy 

and therapeutics, peer review, infection control, surgical case review, special care, blood 

transfusion, utilization management (UM), risk management, and patient safety. The 

QPMC was responsible for setting PI priorities, identifying potential risks, reviewing 

service level PI plans, and for oversight of Education and Safety and EOC Committees. 

Because QM responsibilities were split between the three groups, fragmentation of 

processes occurred, and the committees did not consistently monitor all required areas. 

PI findings need to be evaluated and discussed in interdisciplinary groups that can 

address integrated system issues. 

Managers had appointed PI teams to address discharge issues and clinic access. While 

these teams were effective and their recommendations had resulted in corrective actions, 

there was no documentation of those actions at the local level. Those teams reported 

results to the VISN. The medical center managers agreed that results should be reported 

at the local level in order to facilitate communication to employees. Services had 

developed individual QM plans based on a recommendation from the previous CAP 

report. However, the services had not consistently reported results to the QPMC per local 

VA Office of Inspector General 6 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

policy. QM managers reported that they planned to initiate a reporting schedule starting 

in 2007. 

Peer Review. Although the Peer Review Committee met monthly, clinicians had not 

submitted quarterly reports of trended peer review results to the designated oversight 

committee since 1st quarter FY 2006. As a result, there were no recommendations for 

improving patient care. In addition, not all peer reviews were completed within the VHA 

required timeframe of 120 days. Program managers stated that the person responsible for 

the peer review reports left the position, and no one had taken over the responsibility. 

Documentation of peer review follow-up actions was a cited deficiency in the previous 

CAP report. 

Adverse Event Disclosure. When serious adverse events occur as a result of patient care, 

VHA and local policies require staff to discuss the events with patients and, with input 

from Regional Counsel, inform them of their right to file tort or benefit claims. Those 

discussions must be documented. The medical center reported they had discussed events 

with patients, but there was no documentation of those discussions. 

Reprivileging. JCAHO requires that provider-specific PI results be reviewed as part of 

the reprivileging process. Services are to consider the results to determine if there may 

be a need for education and training. While some limited information was available, it 

needed to be expanded to include meaningful areas, such as medication usage and 

medical records documentation. 

Patient Complaint Analysis. Patient advocates did not trend, analyze, or report patient 

complaints to an oversight committee. VHA policy requires that patient advocates 

aggregate complaints, analyze the data, and present trended reports to senior managers 

and patient care providers. The patient advocates needed to expand data analyses in the 

patient complaint program to include comparisons with SHEP scores and identification of 

meaningful trends. Results needed to be reported to an oversight group to make 

recommendations for corrective action. 

UM. UM review staff collected data in all VHA-required areas but did not consistently 

report results to any oversight group for recommendations and actions to improve clinical 

operations. 

National Patient Safety Goals. JCAHO has developed safety goals that each healthcare 

organization must evaluate and, if not meeting, formulate an action plan to meet those 

goals. The medical center had not established a plan for hand-off communication, 

medication reconciliation at time of admission, or for patients who are placed in 

temporary locations until beds are available for admission. 

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

Center Director requires that: (a) the QM committee structure and reporting process be 

VA Office of Inspector General 7 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

revised; (b) clinicians complete results of peer reviews within the required time frame 

and trend, analyze, and report quarterly results to the Medical Executive Committee; 

(c) clinicians document adverse event disclosure; (d) service chiefs review providerspecific PI data prior to reprivileging; (e) patient advocates trend and analyze patient 

complaints, compare with SHEP scores, and report results; (f) UM staff report results to a 

designated oversight committee for recommendations and corrective actions; and 

(g) action plans be developed for patient safety goals that are not met. 

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

The QM committee structure and reporting process has been reviewed and will be revised 

to ensure there is consistent monitoring and no fragmentation of QM responsibilities. 

The Risk Manager will provide summaries of peer review activities to the Executive 

Committee of the Medical Staff on a quarterly basis. The Risk Manager will review 

patients’ medical records for evidence of documentation of adverse event disclosures. 

Service chiefs will use provider-specific data for reprivileging. Patient advocates will 

compare trended patient complaints with SHEP scores and provide quarterly reports to 

QPMC. A charter team has been established to develop a process to ensure that UM and 

other relevant data is reported to the appropriate oversight committee. Action plans are 

being developed for patient safety goals that are not met. The improvement actions are 

acceptable, and we will follow up on reported implementation actions to ensure they have 

been completed. 

Survey of Healthcare Experiences of Patients – An Action Plan 

Needed To Be Developed for Areas Below Target Scores and Results 

Needed To Be Disseminated to All Medical Center Employees 

Conditions Needing Improvement. The medical center had not met VHA performance 

standards for patient satisfaction, had not disseminated results to employees, and had not 

developed action plans for improvement. Inpatient scores were below the target in 

Access, Coordination of Care, Education and Information, and Emotional Support and 

Transition. Outpatient scores were lower than target in Access, Education and 

Information, Overall Coordination, and Pharmacy Pick-up. If scores are lower than the 

targets, VHA requires medical centers to develop performance improvement action plans. 

The purpose of this review was to assess the extent to which the medical center used the 

results of VHA’s patient satisfaction survey to improve care, treatment, and services. In 

1995, VHA began surveying its patients using a standardized instrument modeled from 

the Picker Institute, a non-profit health care surveying group. VHA set 76 percent of 

inpatients and 77 percent of outpatients rating care as very good or excellent as the 

FY 2006 targets for the results of its SHEP. 

The medical center senior leadership was aware of SHEP results. However, they did not 

widely disseminate the information to other employees or formulate plans to address the 

areas that did not meet the VHA expected scores. 

VA Office of Inspector General 8 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

The table below shows national, VISN 15, and the medical center’s survey results. 

St. Louis VA Medical Center 

Inpatient SHEP Results 1st and 2nd Quarter FY 2006 

Facility Name

AccessCoordination of CareCourtesyEducation & InformationEmotional SupportFamily InvolvementPhysical ComfortPreferencesTransition

VA National 81.31 78.63 89.95 68.02 65.80 75.85 83.41 74.49 70.03

VISN 15 83+ 80.3+ 90.10 67.80 65.40 75.40 83.50 74.30 68.2- 

St. Louis VA Medical Center 70.6- 71- 83.8- 62.9- 58.2- 78.3+ 79.4- 68.3- 62.1- 

St. Louis VA Medical Center 

Outpatient SHEP Results 2nd Quarter 2006 Access Continuity of Care Courtesy Education & Information Emotional Support Overall Coordination Pharmacy Mailed

Pharmacy Pick-upPreferencesSpecialist CareVisit Coordination

National 80.7 78.1 94.8 72.6 83.3 75.8 81.5 65.5 81.7 80.8 84.7

VISN 82 76.9 95 73.9 86.7 + 76.9 84.8 71.9 82.8 79.1 87.6 +

St. Louis Outpatient Clinics - Overall 73.7 - 80.9 90 65.8 79.8 71.5 78.1 50.8 79 76.3 83.3

St. Louis Outpatient Clinic 71.1 - 82.7 88.5 67.5 78 72.2 79.7 48.3 80.4 77.9 83.2

Jefferson Barracks Outpatient Clinic 77.3 79.2 92 61 81.2 69.3 76.9 * 75.9 72 82.7

Belleville Outpatient Clinic 80 77 96.1 73.5 90.4 78.2 77.1 * 84.5 87.6 85.5

St. Louis Veterans Home 74.3 76 89.9 77.3 88.1 75.1 72.4 * 82.6 69.1 87

St. Charles, MO Outpatient Clinic 77.8 71.6 90.1 63.3 76.2 74.4 80 * 73.1 - 80.8 86.6

Springfield CBOC 94 + * 96.3 + * 89.7 + * * * 86.4 + * *

Legend: * Less than 30 respondents 

 + Significantly better than national average 

 - Significantly worse than national average 

Recommendation 4. We recommended that the VISN Director ensure that the Medical 

Center Director requires that (a) SHEP results be shared with medical center employees 

and (b) an action plan be developed and implemented to address satisfaction areas that 

are below the target. 

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

A communication plan has been developed to share the SHEP results across the medical 

center. An in-depth review of the medical center’s SHEP results has been completed, and 

a plan of action to address the major areas of improvement has been developed. The 

improvement actions are acceptable, and we will follow up on reported implementation 

actions to ensure they have been completed. 

VA Office of Inspector General 9 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

Moderate Sedation – Follow-Up of Previously Identified Deficiencies 

Was Insufficient 

Condition Needing Improvement. We determined that managers had not followed up 

on some corrective actions taken in response to moderate sedation deficiencies identified 

in our 2005 CAP report. As a result, some conditions had not been adequately resolved. 

In our 2005 report, we noted that the medical center did not have a policy addressing 

CPR requirements for patient care employees. The medical center’s corrective action 

was to expand the requirement for CPR education to include all medical and dental staff 

and to monitor compliance. 

However, we found that the revised CPR policy still did not require CPR training for all 

employees who provide patient care. We sampled the C&P files of six clinicians who 

provided moderate sedation to determine if they had CPR training. Two (33 percent) of 

the six clinicians did not have current CPR training. 

Recommendation 5. We recommended that the VISN Director ensure that the Medical 

Center Director takes action to (a) revise the CPR policy to include the requirement that 

all patient care employees have CPR training and (b) monitor CPR training compliance. 

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

The CPR policy will be revised to ensure that all clinically active employees have CPR 

training. Compliance with CPR training will be tracked by administrative officers or 

business managers for each service or program. The improvement actions are acceptable, 

and we will follow up on reported implementation actions to ensure they have been 

completed. 

Other Review Topics 

Breast Cancer Management 

The medical center provided timely breast cancer screening and follow up, utilizing onsite mammography and biopsy services. Reports were timely, and patients were 

promptly notified of results of diagnostic testing and biopsies. Surgery and oncology 

consultative and treatment services were promptly provided. 

The VHA breast cancer screening performance measure assesses the percent of patients 

screened according to prescribed timeframes. The medical center achieved the fully 

satisfactory level for all quarters in FY 2005.

VA Office of Inspector General 10 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

Breast Cancer Screening

St. Louis VA Medical Center

85 85

91

87 88

100

86

83 83 83

84 86

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

Qtr 1 Qtr 2 Qtr 3 Qtr 4

Percent

Facility

VISN

National

FY 2005 Performance Measure Scores Better

Fully 

Satisfactory 

Score = 85%

Patients 

appropriately 

screened 

Mammography 

results reported 

to patient 

within 30 days 

Patients 

appropriately 

notified of their 

diagnoses 

Patients received 

timely 

consultations 

Patients 

received timely 

biopsy 

procedure 

10/10 10/10 10/10 10/10 10/10 

Timely diagnosis, notification, interdisciplinary treatment planning, and treatment are 

essential to early detection, appropriate management, and optimal patient outcomes. We 

reviewed these items in a random sample of 10 patients who had abnormal 

mammography findings during FY 2005. Because the medical center provided 

appropriate screening and timely services for all 10 patients, we did not make any 

recommendations. 

Community Based Outpatient Clinics 

The purpose of this review was to assess the effectiveness of CBOC operations and to 

determine whether CBOCs are in compliance with selected standards of operation. 

We selected one CBOC for review. We interviewed key staff at the medical center and 

the CBOC; reviewed documentation and self-assessment tools; and reviewed 

credentialing, education, and background checks for five selected clinicians. Three 

VA Office of Inspector General 11 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

physicians’ files and two nurses’ files were randomly selected for review. All files 

contained documentation of licensure, credentialing, mandatory education, and 

background checks. 

We interviewed eight patients who were being treated at the CBOC the day of our 

inspection. All patients reported a high level of satisfaction with their providers and the 

care they receive at the CBOC. We reviewed the CBOC warfarin1

 clinic and found 

evidence that the same standards of care provided to patients at the medical center are in 

effect at the CBOC. A clinical pharmacist manages the warfarin patients at both 

facilities. Mental health patients are treated at the CBOC via telemedicine by a 

psychologist located at the medical center. 

We also inspected the CBOC environment of care. The facility was clean and safe with 

current emergency preparedness plans and training. The Automated External 

Defibrillator was inspected, and documentation was current. 

We found that the CBOC was in compliance with all expected regulations and standards; 

therefore, we made no recommendations. 

Contract Community Nursing Homes 

CNH Program staff provided appropriate and comprehensive oversight of the community 

nursing homes caring for veterans. We reviewed the CNH Program to assess compliance 

with local and national policies regarding the selection of contract homes, the review 

process for contract renewal, and the monitoring of patients in contract CNHs. We 

evaluated whether patients received rehabilitation services (speech, physical, or 

occupational therapy) when ordered and whether there were effective processes in place 

to more closely monitor the contract CNHs if deficiencies had been identified. 

The medical center had 54 veterans under contract in 12 CNHs. We selected five homes 

for review and conducted a site visit at one. We interviewed the administrators at this 

site, inspected the facility, and interviewed patients. We also conducted 10 patient record 

reviews. 

The CNH review team utilized the exclusion review reports, including quality indicators, 

in order to conduct their annual review of each facility. The CNH Program staff 

collected and reviewed PI data from the contract CNHs contained on the Medicare 

internet site. Contract renewal recommendations were based on these reviews, as well as 

information gained from site inspections done by the team. The CNH Program staff was 

aware of their options to utilize increased monitoring, suspension of placements, and 

contract termination, when warranted. No contracts had been terminated as a result of 

non-compliance. 

 

1 Warfarin is a medication used to prevent blood clots. 

VA Office of Inspector General 12 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

Social work and nursing staff conducted monthly patient visits and documented patient 

assessments and discussions of concerns regarding care in the medical records. The 

administrators, nursing directors, and patients reported that the CNH staff was accessible 

and responsive to their needs and concerns. We confirmed that patients received services 

as ordered, and the program provided appropriate oversight. Therefore, we did not make 

any recommendations. 

Diabetes and Atypical Antipsychotic Medications 

Clinicians appropriately screened and managed mental health patients receiving atypical 

antipsychotic medications. The purpose of this review was to determine the effectiveness 

of diabetes screening, monitoring, and treatment of mental health patients receiving 

atypical antipsychotic medications (medications that cause fewer neurological side 

effects but increase the patient’s risk for the development of diabetes). 

VHA clinical practice guidelines for the management of diabetes suggest that: a diabetic 

patient’s hemoglobin A1c (HbA1c)2

 should be less than 9 percent; blood pressure should 

be 140/90 millimeters of mercury (mmHg) or less; and low density lipoprotein 

cholesterol (LDL-C) should be less than 120 milligrams per deciliter (mg/dl). To receive 

fully satisfactory ratings for the diabetes performance measures, the medical center must 

achieve the following scores: 

• HbA1c greater than 9 percent – 15 percent or lower 

• Blood pressure less than or equal to 140/90mmHg – 72 percent or higher 

• LDL-C less than 120mg/dl – 75 percent or higher 

We reviewed the medical records of 13 randomly selected patients who were on one or 

more atypical antipsychotic medications for at least 90 days. Three of the 13 patients had 

diabetes. All patients were screened for diabetes and counseled about prevention. 

Providers utilize an electronic clinical reminder to notify clinicians about patients’ health 

maintenance requirement schedules. 

Diabetic 

patients with 

HbA1c 

greater than 

9 percent 

Diabetic 

patients with 

blood pressure 

less than 

140/90 mm/Hg 

Diabetic 

patients with 

LDL-C less 

than 120mg/dl 

Non-diabetic 

patients 

appropriately 

screened 

Non-diabetic patients 

who received diabetes 

prevention counseling 

0/3 3/3 3/3 10/10 10/10 

 

2

 HbA1c reflects the average blood glucose level over a period of time and should remain in control to prevent 

complications. 

VA Office of Inspector General 13 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

The review showed that the medical center met or exceeded VHA performance measures 

for LDL-C control for FY 2005. Clinical staff had identified areas for improvement and 

implemented appropriate action plans. Because senior managers had analyzed 

performance measure results and supported the corrective actions for meeting these 

measures, we made no recommendations. 

Diabetes Detection and Management

LDL-C Less Than 120

St. Louis VA Medical Center

76

79

78

79

84

80

78

82 82 83

75 77

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

Qtr 1 Qtr 2 Qtr 3 Qtr 4

Percent

Facility

VISN

National

Better

FY 2005 Performance Measure Scores

Fully 

Satisfactory 

Score = 75

VA Office of Inspector General 14 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum

Date: December 11, 2006 

From: Director, Veterans Integrated Service Network (10N15) 

Subject: St. Louis VA Medical Center, St. Louis, Missouri

To: Kansas City Regional Office of Healthcare Inspections 

I have reviewed and concur with the responses to the 

recommendations and action plans as outlined by the St. 

Louis VAMC. 

 (original signed by:) 

 PETER L. ALMENOFF, M.D., FCCP

VA Office of Inspector General 15 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri

Appendix B 

Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum

Date: December 7, 2006 

From: Director, St. Louis VA Medical Center (657/00) 

Subject: St. Louis VA Medical Center St. Louis, Missouri

To: Director, VISN 15 

Attached is the St. Louis VA Medical Center response and 

actions plan to the OIG report from the Combined 

Assessment Program that was conducted on October 2–6, 

2006. 

(original signed by:) 

GLEN E. STRUCHTEMEYER 

VA Office of Inspector General 16 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri

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 

Report: 

OIG Recommendations

Recommendation 1. We recommended that the VISN 

Director ensure that the Medical Center Director requires 

that: (a) clinicians meet all requirements for completing 

informed consents, (b) cardiac catheterization laboratory 

physicians receive CPR training or document CPR 

proficiency, and (c) the cardiac catheterization laboratory 

develop a quality improvement review process and report 

findings to the designated oversight committee on at least a 

quarterly basis. 

Concur Target Completion Date: February 28, 2007 

(a) The sample of records reviewed as part of the OIG CAP 

review included patients seen in FY05. At that time, 

documentation of informed consent was on a paper form with 

multiple fields to be completed by the clinician. In FY06, the 

electronic informed consent process (iMED) was 

implemented. The iMED process forced all fields to be 

completed and has plain language descriptions for all 

procedures. A random sample of 20 patients that underwent 

cardiac catheterization in the 4th quarter of FY06 was 

reviewed for compliance; 20 of 20 records were compliant for 

the required elements. (Completed November 21, 2006) 

(b) Documentation of CPR training for each of the Cardiac 

Cath Lab physician was obtained after the OIG CAP review 

exit. Review of the documentation showed that each 

physician was and remains current in their certification. 

(Completed December 1, 2006) 

VA Office of Inspector General 17 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri

(c) The Cardiac Catheterization Laboratory will develop a 

quality improvement process reflective of the qualitative, 

quantitative, and process outcomes of the Cardiac 

Catheterization Laboratory procedures. The results will be 

reported to the Medical Staff Performance Improvement 

Committee no less than quarterly. 

Recommendation 2. We recommended that the VISN 

Director ensure that the Medical Center Director requires 

that: (a) ceiling air vents are routinely checked and cleaned; 

(b) filters in window air conditioning units are inspected 

quarterly during EOC rounds and changed as needed; (c) 

window sills are regularly cleaned; (d) all clean linen, 

including cloth bags used for isolation gowns, be secured and 

not stored on the floor; and (e) all refrigerators are checked 

daily for the presence of thermometers and recorded 

temperatures. 

Concur Target Completion Date: January 31, 2007 

(a) EMS supervisors have re-instructed staff on the checking 

and cleaning of the vents as part of daily work assignments. 

Supervisors will include checking vents as part of daily 

inspections. (Completed December 1, 2006) The 

Engineering Service handymen will perform a through 

cleaning of the inside of the vent and grill on a semiannual 

basis. (Began October 2006) 

(b) A quarterly preventative maintenance (PM) schedule for 

window air conditioners was established to include 

replacement of filters. This will be monitored as part of 

Environment of Care rounds. (Began October 2006) 

(c) Environmental Management Service (EMS) supervisors 

have re-instructed staff on dusting horizontal and flat surfaces 

as part of daily work assignments. Supervisors will include 

checking flat surfaces as part of daily inspections. 

(Completed December 1, 2006). 

VA Office of Inspector General 18 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri

(d) The storage of cloth bags containing isolation gowns has 

been changed from the placement on the linen cart to being 

hung on a hook on the wall of the linen closet. This will 

allow easy access to the gowns and keep them off the floor. 

Work orders have been submitted for all closets as of 

December 4, 2006. This will be monitored as part of 

Environment of Care rounds. (Began October 2006) 

(e) The refrigerators temperature log will be changed from a 

6 month log sheet to a monthly log sheet to allow for the 

recording of the presence of a thermometer and temperature. 

Action will be taken when a thermometer is not present or the 

temperature is out of range. This will be monitored as part of 

the Environment of Care Rounds. 

Recommendation 3. We recommended that the VISN 

Director ensure that the Medical Center Director requires 

that: (a) the QM committee structure and reporting process be 

revised; (b) clinicians complete results of peer reviews within 

the required time frame and trend, analyze, and report 

quarterly results to Medical Executive Committee; (c) 

clinicians document adverse event disclosure; (d) service 

chiefs review provider-specific PI data prior to reprivileging; 

(e) patient advocates trend and analyze patient complaints, 

compare with SHEP scores, and report results; (f) UM staff 

report results to a designated oversight committee for 

recommendations and corrective actions; and (g) action plans 

be developed for patient safety goals that are not met. 

Concur Target Completion Date: February 28, 2007 

(a) The Executive Management team reviewed the QM 

committee structure and reporting process (Completed 

October 2006). The VISN 15 Quality Management Officer 

provided consultation on structure within other VISN 15 

facilities for local review (Completed November 2006). The 

Quality Manager and Chief of Staff will review structures at 

other similarly complex VA facilities. The Executive 

Management team will finalize a revised QM committee 

structure and reporting process that ensures there is consistent 

monitoring and no fragmentation of QM responsibilities. 

VA Office of Inspector General 19 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri

(b) The Risk Manager provided an annual report of FY06 

Peer Review activities to the Executive Committee of the 

Medical Staff in October 2006. This report included 

quarterly summaries of activities that had not been reported 

on and a cumulative summary. Quarterly reports are 

provided to the ECMS. (Beginning October 2006). 

(c) Adverse events are routinely reviewed at the weekly 

Patient Safety Council meetings. Subsequent to this review, 

the Risk Manager reviews the patient’s electronic medical 

record as evidence of documentation of clinical disclosures. 

For events that rise to the level of institutional disclosure, the 

Risk Manager will complete an entry in the patient medical 

record using a template note. Disclosure status is included in 

the final Root Cause Analysis (RCA) reports to the 

Director/Chief of Staff. (Completed November 2006) 

(d) The Medical and Dental staff will identify data elements 

to be used in ongoing professional practice evaluation. 

Elements will be specific to the privileges. IRM will 

complete programming to generate reports. Once completed 

the reports will be routinely produced and sent to the provider 

and supervisor and included as part of the reprivileging 

process. 

(e) A Patient Advocate representative is a member of the 

Quality and Performance Management Council. They will 

provide a quarterly report of trends and analysis of data 

collected through the patient advocate database. A 

comparison of the medical center SHEP scores will be 

included. 

(f) A charter team has been established to develop a process 

to ensure appropriate review and dissemination of relevant 

data. The team recommendations will be reviewed by 

Quality and Performance Management Council. 

Subsequently the council will make a recommendation action 

to the Executive Leadership Council. Once approved, the 

Utilization Management Plan and reporting will be 

implemented. 

VA Office of Inspector General 20 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri

(g) Action plans are being developed to address the National 

Patient Safety Goals that are not met. The plans will be 

reviewed and approved by the Patient Safety Committee. 

Once approved, implementation and monitoring will occur. 

Recommendation 4. We recommended that the VISN 

Director ensure that the Medical Center Director requires that 

(a) SHEP results be shared with medical center employees 

and (b) an action plan be developed and implemented to 

address satisfaction areas that are below the target. 

Concur Target Completion Date: January 31, 2007 

(a) A communication plan has been developed to share the 

SHEP results across the medical center. This includes 

quarterly reports to Executive Leadership Council, Executive 

Committee of the Medical Staff, Performance Improvement 

Committee, Quality and Performance Management Council, 

Programs, Services, Managers and Supervisors. A quarterly 

update will be provided to employees via the medical center's 

Employee Newsletter. Access to the NCR+Picker website 

will be expanded and training provided on how to use the site. 

(Began December 1, 2006) 

(b) An in-depth review of the Medical Center's SHEP results 

has been completed. A plan of action to address the major 

areas of improvement has been developed. Implementation 

has begun. (December 1, 2006) 

Recommendation 5. We recommended that the VISN 

Director ensure that the Medical Center Director takes action 

to (a) revise the CPR policy to include the requirement that all 

patient care employees have CPR training and (b) monitor 

CPR training compliance. 

Concur Target Completion Date: February 28, 2007 

(a) The CPR policy will be revised to include that all 

clinically active employees have CPR training 

(b) Compliance with CPR training will be tracked by 

Administrative Officers or Business Managers for each 

service or program. A report of compliance will be submitted 

to the Chief of Staff Office for review. 

VA Office of Inspector General 21 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Virginia L. Solana, Director 

Kansas City Regional Office of Healthcare Inspections 

816/426-2023 

Acknowledgments Dorothy Duncan 

Jennifer Kubiak 

Reba Ransom 

Marilyn Stones 

Jim Werner 

VA Office of Inspector General 22 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network 15 (10N15) 

Director, St. Louis VA Medical Center (657/00) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction and Veterans Affairs 

House Committee on Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction and Veterans Affairs 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: 

 Christopher Bond 

 Claire McCaskill 

U.S. House of Representatives: 

 Todd Akin 

 Russ Carnahan 

 William Lacy Clay, Jr. 

 Jo Ann Emerson 

 Kenny Hulshof 

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

VA Office of Inspector General 23