Department of Veterans Affairs
Office of Inspector General

Office of Healthcare Inspections
Report No. 14-04215-99

Combined Assessment Program 

Review of the 

Cincinnati VA Medical Center 

Cincinnati, Ohio 


February 4, 2015
Washington, DC 20420

 To Report Suspected Wrongdoing in VA Programs and Operations
Telephone: 1-800-488-8244
E-Mail: vaoighotline@va.gov
(Hotline Information: www.va.gov/oig/hotline)

 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

Glossary
CAP

Combined Assessment Program

CLC

community living center

EAM

emergency airway management

EHR

electronic health record

EOC

environment of care

facility

Cincinnati VA Medical Center

FY

fiscal year

ICU

intensive care unit

MH

mental health

MRI

magnetic resonance imaging

NA

not applicable

NM

not met

OIG

Office of Inspector General

QM

quality management

RRTP

residential rehabilitation treatment program

VHA

Veterans Health Administration

VISN

Veterans Integrated Service Network

VA OIG Office of Healthcare Inspections

 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

Table of Contents 

Page 


Executive Summary ...................................................................................................

i


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

1

1

1


Reported Accomplishments......................................................................................

2


Results and Recommendations ................................................................................
QM ..........................................................................................................................
EOC ........................................................................................................................
Medication Management.........................................................................................
Coordination of Care ...............................................................................................
MRI Safety ..............................................................................................................
Acute Ischemic Stroke Care ...................................................................................
Surgical Complexity ................................................................................................
EAM ........................................................................................................................
MH RRTP ...............................................................................................................

4

4

8

12

15

16

18

20

21

23


Appendixes
A. Facility Profile ....................................................................................................
B. Strategic Analytics for Improvement and Learning ............................................
C. VISN Director Comments ..................................................................................
D. Acting Facility Director Comments ....................................................................
E. Office of Inspector General Contact and Staff Acknowledgments .....................
F. Report Distribution .............................................................................................
G. Endnotes ...........................................................................................................

25

26

29

30

34

35

36


VA OIG Office of Healthcare Inspections

 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

Executive Summary 

Review Purpose: The purpose of the review was to evaluate selected health care
facility operations, focusing on patient care quality and the environment of care, and to
provide crime awareness briefings.
We conducted the review the week of
October 20, 2014.

Review Results:

The review covered nine activities.
recommendations in the following three activities:

We made no

 Magnetic Resonance Imaging Safety
 Acute Ischemic Stroke Care
 Emergency Airway Management
The facility’s reported accomplishments were receipt of a 2014 Federal Service
Excellence Award for the Hospital-In-Home program and local implementation of the
national telemedicine intensive care unit program.

Recommendations: We made recommendations in the following six activities:
Quality Management: Ensure licensed independent practitioners’ privileging folders do
not contain licensure verification information.
Environment of Care: Store clean and dirty items separately.
monitors from public viewing on the medical and surgical units.

Protect computer

Medication Management: Revise the policy for safe use of automated dispensing
machines to include employee training and minimum competency requirements for
users.
Coordination of Care: Designate a committee to oversee consult management. Ensure
Automated Data Processing Applications Coordinators provide training in the use of the
computerized consult package.
Surgical Complexity: Revise the Radiology Service computed tomography scan and
magnetic resonance imaging on-call policy to require a 30-minute reporting time.
Ensure post-anesthesia care competency assessment and validation is completed for
employees on the surgical intensive care unit.
Mental Health Residential Rehabilitation Treatment Program: Ensure Domiciliary Care
for Homeless Veterans and Post-Traumatic Stress Disorder Program employees
conduct and document monthly self-inspections.

VA OIG Office of Healthcare Inspections

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

Comments
The Veterans Integrated Service Network and Acting Facility Directors agreed with the
Combined Assessment Program review findings and recommendations and provided
acceptable improvement plans. (See Appendixes C and D, pages 29–33, for the full
text of the Directors’ comments.) We will follow up on the planned actions until they are
completed.

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

Assistant Inspector General for 

Healthcare Inspections


VA OIG Office of Healthcare Inspections

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

Objectives and Scope 

Objectives
CAP reviews are one element of the OIG’s efforts to ensure that our Nation’s veterans
receive high quality VA health care services. The objectives of the CAP review are to:
  Conduct recurring evaluations of selected health care facility operations, focusing
on patient care quality and the EOC.
  Provide crime awareness briefings to increase employee understanding of the
potential for program fraud and the requirement to refer suspected criminal
activity to the OIG.

Scope
The scope of the CAP review is limited. Serious issues that come to our attention that
are outside the scope will be considered for further review separate from the CAP
process and may be referred accordingly.
For this review, we examined selected clinical and administrative activities to determine
whether facility performance met requirements related to patient care quality and the
EOC. In performing the review, we inspected selected areas, conversed with managers
and employees, and reviewed clinical and administrative records. The review covered
the following nine activities:
  QM
  EOC
  Medication Management
  Coordination of Care
  MRI Safety
  Acute Ischemic Stroke Care
  Surgical Complexity
  EAM
  MH RRTP
We have listed the general information reviewed for each of these activities. Some of
the items listed may not have been applicable to this facility because of a difference in
size, function, or frequency of occurrence.

VA OIG Office of Healthcare Inspections

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

The review covered facility operations for FY 2014 and FY 2015 through
October 20, 2014, and was done in accordance with OIG standard operating
procedures for CAP reviews. We also asked the facility to provide the status on the
recommendations we made in our previous CAP report (Combined Assessment
Program Review of the Cincinnati VA Medical Center, Cincinnati, Ohio, Report
No. 11-03666-79, February 13, 2012).
During this review, we presented crime awareness briefings for 102 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.
Additionally, we surveyed employees regarding patient safety and quality of care at the
facility. An electronic survey was made available to all facility employees, and
624 responded. We shared summarized results with facility managers.
In this report, we make recommendations for improvement. Recommendations pertain
to issues that are significant enough to be monitored by the OIG until corrective actions
are implemented.

Reported Accomplishments 

Hospital-In-Home Program
On April 17, 2014, the Greater Cincinnati Federal Executive Board presented the
facility’s Hospital-In-Home program with a Federal Service Excellence Award for
Outstanding Project Team.
The Hospital-In-Home program provides advanced, intensive therapy to patients in their
homes and helps reduce both readmission rates and the number of days a patient stays
in the hospital. In addition, the program provides a solution to hospital bed shortage.
Patients who qualify medically for the program and agree to participate receive daily
visits from a nurse and regularly communicate with their physician. The use of
computerized video telehealth is being initiated, which will make face-to-face doctor
visits possible.
In its first year, the Hospital-In-Home program helped reduce the congestive heart
failure readmission rate by more than 20 percent and helped the facility save an
estimated $1 million. Additionally, the patient satisfaction rate has consistently been
between 95 and 100 percent.

National Telemedicine ICU Program
The telemedicine ICU program uses a combination of technologies, such as audiovisual
communication, EHRs, sophisticated computer systems, and patient monitoring
technology, to create a link between the facility and other ICUs in VISNs 7 and 10. The

VA OIG Office of Healthcare Inspections

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

program allows constant monitoring of critically ill patients even when the local nurses
and doctors are out of the room assisting other critically ill patients.
Facility nurses and doctors with specialized training in critical care medicine staff the
program 365 days a year, 24 hours per day. They have access to remote data such as
vital signs, electrocardiograms, and EHRs. They are also able to speak with the
patients, doctors, and nurses at the remote facility via video conferencing technology.
Facility staff can directly intervene or consult with remote medical staff. The
telemedicine ICU program is not meant as a replacement for the doctors and nurses
caring for the patients at the remote site. It enhances patient care by encouraging
adherence to critical care guidelines, augments bedside teaching for residents and
medical students, and elevates the level of critical care services provided to veteran
patients throughout the two VISNs, which have a total of 11 hospitals, 16 ICUs, and
197 ICU beds.

VA OIG Office of Healthcare Inspections

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

Results and Recommendations 

QM
The purpose of this review was to determine whether facility senior managers actively supported and appropriately responded to QM
efforts and whether the facility met selected requirements within its QM program.a
We conversed with senior managers and key QM employees, and we evaluated meeting minutes, 10 credentialing and privileging
folders, and other relevant documents. The table below shows the areas reviewed for this topic. The area marked as NM did not meet
applicable requirements and needed improvement. Any items that did not apply to this facility are marked NA.
NM

Areas Reviewed
There was a senior-level committee
responsible for key quality, safety, and value
functions that met at least quarterly and was
chaired or co-chaired by the Facility Director.
 The committee routinely reviewed
aggregated data.
 QM, patient safety, and systems redesign
appeared to be integrated.
Peer reviewed deaths met selected
requirements:
 Peers completed reviews within specified
timeframes.
 The Peer Review Committee reviewed
cases receiving initial Level 2 or 3 ratings.
 Involved providers were invited to provide
input prior to the final Peer Review
Committee determination.

VA OIG Office of Healthcare Inspections

Findings

Recommendations

4

 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

NM
X

Areas Reviewed (continued)
Credentialing and privileging processes met
selected requirements:
 Facility managers reviewed privilege forms
annually and ensured proper approval of
revised forms.
 Facility managers ensured appropriate
privileges for licensed independent
practitioners.
 Facility managers removed licensed
independent practitioners’ access to
patients’ EHRs upon separation.
 Facility managers properly maintained
licensed independent practitioners’ folders.
Observation bed use met selected
requirements:
 The facility gathered data regarding
appropriateness of observation bed
usage.
 The facility reassessed observation
criteria and/or utilization if conversions to
acute admissions were consistently
25–30 percent or more.
The process to review resuscitation events
met selected requirements:
 An interdisciplinary committee reviewed
episodes of care where resuscitation was
attempted.
 Resuscitation event reviews included
screening for clinical issues prior to events
that may have contributed to the
occurrence of the code.
 The facility collected data that measured
performance in responding to events.

VA OIG Office of Healthcare Inspections

Findings
 Five of the 10 licensed independent
practitioners’ folders contained licensure
verification information.

Recommendations
1. We recommended that the facility ensure
that licensed independent practitioners’
folders do not contain licensure verification
information.

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

NM

Areas Reviewed (continued)
The surgical review process met selected
requirements:
 An interdisciplinary committee with
appropriate leadership and clinical
membership met monthly to review
surgical processes and outcomes.
 The Surgical Work Group reviewed
surgical deaths with identified problems or
opportunities for improvement.
 The Surgical Work Group reviewed
additional data elements.
Clinicians appropriately reported critical
incidents.
The safe patient handling program met
selected requirements:
 A committee provided program oversight.
 The facility gathered, tracked, and shared
patient handling injury data.
The process to review the quality of entries
in the EHR met selected requirements:
 A committee reviewed EHR quality.
 A committee analyzed data at least
quarterly.
 Reviews included data from most services
and program areas.
The policy for scanning internal forms into
EHRs included the following required items:
 Quality of the source document and an
alternative means of capturing data when
the quality of the document is inadequate.
 A correction process if scanned items
have errors.

VA OIG Office of Healthcare Inspections

Findings

Recommendations

6

 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

NM

Areas Reviewed (continued)
 A complete review of scanned documents
to ensure readability and retrievability of
the record and quality assurance reviews
on a sample of the scanned documents.
Overall, if QM reviews identified significant
issues, the facility took actions and
evaluated them for effectiveness.
Overall, the facility had a comprehensive,
effective QM program over the past
12 months.
The facility met any additional elements
required by VHA or local policy.

VA OIG Office of Healthcare Inspections

Findings

Recommendations

7

 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

EOC
The purpose of this review was to determine whether the facility maintained a clean and safe health care environment in accordance
with applicable requirements. We also determined whether the facility met selected requirements in critical care and the CLC.b
We inspected the primary care clinic, the Emergency Department, the locked MH unit, medical (6N) and surgical (5N) units, medical
and surgical ICUs, and the CLC. We also performed a perimeter inspection of the respiratory therapy room construction site in 5N.
Additionally, we reviewed relevant documents, including inspection documentation for 10 alarm-equipped medical devices in critical
care, and 30 employee training records (20 critical care and 10 CLC) and conversed with key employees and managers. The table
below shows the areas reviewed for this topic. The areas marked as NM did not meet applicable requirements and needed
improvement. Any items that did not apply to this facility are marked NA.
NM

Areas Reviewed for General EOC
EOC Committee minutes reflected sufficient
detail regarding identified deficiencies,
corrective actions taken, and tracking of
corrective actions to closure for the facility
and the community based outpatient clinics.
The facility conducted an infection
prevention risk assessment.
Infection Prevention/Control Committee
minutes documented discussion of identified
high-risk areas, actions implemented to
address those areas, and follow-up on
implemented actions and included analysis
of surveillance activities and data.
The facility had established a process for
cleaning equipment.
Selected employees received training on
updated requirements regarding chemical
labeling and safety data sheets.
The facility met fire safety requirements.
The facility met environmental safety
requirements.

VA OIG Office of Healthcare Inspections

Findings

Recommendations

8

 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

NM
X

X

Areas Reviewed for General EOC
(continued)
The facility met infection prevention
requirements.
The facility met medication safety and
security requirements.
The facility met privacy requirements.

Findings

Recommendations

 One of five patient care areas had clean
and dirty items stored together.

2. We recommended that the facility store
clean and dirty items separately and that
facility managers monitor compliance.

 The positioning of computer monitors on
the medical and surgical units did not
restrict public viewing.

3. We recommended that the facility
appropriately protect computer monitors from
public viewing on the medical and surgical
units and that facility managers monitor
compliance.

The facility complied with any additional
elements required by VHA, local policy, or
other regulatory standards.
Areas Reviewed for Critical Care
Designated critical care employees received
bloodborne pathogens training during the
past 12 months.
Alarm-equipped medical devices used in
critical care were inspected/checked
according to local policy and/or
manufacturers’ recommendations.
The facility met fire safety requirements in
critical care.
The facility met environmental safety
requirements in critical care.
The facility met infection prevention
requirements in critical care.
The facility met medication safety and
security requirements in critical care.
The facility met medical equipment
requirements in critical care.
The facility met patient privacy requirements
in critical care.

VA OIG Office of Healthcare Inspections

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

NM

NA

X

Areas Reviewed for Critical Care
(continued)
The facility complied with any additional
elements required by VHA, local policy, or
other regulatory standards.
Areas Reviewed for CLC
Designated CLC employees received
bloodborne pathogens training during the
past 12 months.
For CLCs with resident animal programs, the
facility conducted infection prevention risk
assessments and had policies addressing
selected requirements.
For CLCs with elopement prevention
systems, the facility documented
functionality checks at least every 24 hours
and documented complete system checks
annually.
The facility met fire safety requirements in
the CLC.
The facility met environmental safety
requirements in the CLC.
The facility met infection prevention
requirements in the CLC.

Findings

 Dirty wheelchairs and a soiled shower
litter were stored in the clean equipment
storage room.

Recommendations

See recommendation 2.

The facility met medication safety and
security requirements in the CLC.
The facility met medical equipment
requirements in the CLC.
The facility met privacy requirements in the
CLC.
The facility complied with any additional
elements required by VHA, local policy, or
other regulatory standards.

VA OIG Office of Healthcare Inspections

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

NM

Areas Reviewed for Construction Safety
The facility met selected dust control,
temporary barrier, storage, and security
requirements for the construction site
perimeter.
The facility complied with any additional
elements required by VHA or local policy, or
other regulatory standards.

VA OIG Office of Healthcare Inspections

Findings

Recommendations

11

 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

Medication Management
The purpose of this review was to determine whether the facility had established safe medication storage practices in accordance with
VHA policy and Joint Commission standards.c
We reviewed relevant documents, the training records of 20 nursing employees, and pharmacy monthly medication storage area
inspection documentation for the past 6 months. Additionally, we inspected the medical ICU, CLC, Emergency Department, and
medical and surgical units and for these areas reviewed documentation of narcotic wastage from automated dispensing machines and
inspected crash carts containing emergency medications. The table below shows the areas reviewed for this topic. The area marked
as NM did not meet applicable requirements and needed improvement. Any items that did not apply to this facility are marked NA.
NM

Areas Reviewed
Facility policy addressed medication receipt
in patient care areas, storage procedures
until administration, and staff authorized to
have access to medications and areas used
to store them.
The facility required two signatures on
controlled substances partial dose wasting.
The facility defined those medications and
supplies needed for emergencies and
procedures for crash cart checks, checks
included all required elements, and the
facility conducted checks with the frequency
required by local policy.
The facility prohibited storage of potassium
chloride vials in patient care areas.
If the facility stocked heparin in
concentrations of more than 5,000 units per
milliliter in patient care areas, the Chief of
Pharmacy approved it.

VA OIG Office of Healthcare Inspections

Findings

Recommendations

12

 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

NM

X

Areas Reviewed (continued)
The facility maintained a list of the look-alike
and sound-alike medications it stores,
dispenses, and administers; reviewed this
list annually and ensured it was available for
staff reference; and had labeling/storage
processes to prevent errors.
The facility identified in writing its high-alert
and hazardous medications, ensured the
high-alert list was available for staff
reference, and had processes to manage
these medications.
The facility conducted and documented
inspections of all medication storage areas
at least every 30 days, fully implemented
corrective actions, and monitored the
changes.
The facility/Pharmacy Service had a written
policy for safe use of automated dispensing
machines that included oversight of
overrides and employee training and
minimum competency requirements for
users, and employees received training or
competency assessment in accordance with
local policy.
The facility employed practices to prevent
wrong-route drug errors.
Medications prepared but not immediately
administered contained labels with all
required elements.
The facility removed medications awaiting
destruction or stored them separately from
medications available for administration.
The facility met multi-dose insulin pen
requirements.

VA OIG Office of Healthcare Inspections

Findings

 Facility policy for safe use of automated
dispensing machines did not include
employee training and minimum
competency requirements for users.

Recommendations

4. We recommended that the facility revise
the policy for safe use of automated
dispensing machines to include employee
training and minimum competency
requirements for users and that facility
managers monitor compliance.

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

NM

Areas Reviewed (continued)
The facility complied with any additional
elements required by VHA or local policy.

VA OIG Office of Healthcare Inspections

Findings

Recommendations

14

 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

Coordination of Care
The purpose of this review was to evaluate the consult management process and the completion of inpatient clinical consults.d
We reviewed relevant documents, and we conversed with key employees. Additionally, we reviewed the EHRs of 32 randomly selected
patients who had a consult requested during an acute care admission from January 1 through June 30, 2014. The table below shows
the areas reviewed for this topic. The areas marked as NM did not meet applicable requirements and needed improvement. Any items
that did not apply to this facility are marked NA.
NM
X

X

Areas Reviewed
A committee oversaw the facility’s consult
management processes.

Findings
 The facility did not have a committee to
oversee consult management.

Major bed services had designated
employees to:
 Provide training in the use of the
computerized consult package
 Review and manage consults
Consult requests met selected requirements:
 Requestors included the reason for the
consult.
 Requestors selected the proper consult
title.
 Consultants appropriately changed consult
statuses, linked responses to the requests,
and completed consults within the
specified timeframe.
The facility met any additional elements
required by VHA or local policy.

 The Automated Data Processing
Applications Coordinators did not provide
training in the use of the computerized
consult package.

VA OIG Office of Healthcare Inspections

Recommendations
5. We recommended that the facility
designate a committee to oversee consult
management.
6. We recommended that the Automated
Data Processing Applications Coordinators
provide training in the use of the
computerized consult package and that
facility managers monitor compliance.

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

MRI Safety
The purpose of this review was to determine whether the facility ensured safety in MRI in accordance with VHA policy requirements
related to: (1) staff safety training, (2) patient screening, and (3) risk assessment of the MRI environment.e
We reviewed relevant documents and the training records of 37 employees (30 randomly selected Level 1 ancillary staff and
7 designated Level 2 MRI personnel), and we conversed with key managers and employees. We also reviewed the EHRs of
35 randomly selected patients who had an MRI January 1–December 31, 2013. Additionally, we conducted physical inspections of two
MRI areas.   The table below shows the areas reviewed for this topic. Any items that did not apply to this facility are marked NA. The
facility generally met requirements. We made no recommendations.
NM

Areas Reviewed
The facility completed an MRI risk
assessment, had documented procedures
for handling emergencies in MRI, and
conducted emergency drills in the MRI area.
Patients had two safety screenings
conducted prior to MRI; the patient, family
member, or caregiver signed the secondary
patient safety screening form; and a Level 2
MRI personnel reviewed and signed the
secondary patient safety screening form.
Secondary patient safety screening forms
contained notations of any MRI
contraindications, and a Level 2 MRI
personnel and/or radiologist addressed the
contraindications and documented resolution
prior to MRI.
The facility designated Level 1 ancillary staff
and Level 2 MRI personnel and ensured they
received level-specific annual MRI safety
training.

VA OIG Office of Healthcare Inspections

Findings

Recommendations

16

 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

NM

Areas Reviewed (continued)
The facility had signage and barriers in place
to prevent unauthorized or accidental access
to Zones III and IV.
MRI technologists maintained visual contact
with patients in the magnet room and
two-way communication with patients inside
the magnet, and the facility regularly tested
the two-way communication device.
The facility provided patients with MRI-safe
hearing protection for use during the scan.
The facility had only MRI-safe or compatible
equipment in Zones III and IV or
appropriately protected the equipment from
the magnet.
The facility complied with any additional
elements required by VHA or local policy.

VA OIG Office of Healthcare Inspections

Findings

Recommendations

17

 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

Acute Ischemic Stroke Care
The purpose of this review was to determine whether the facility complied with selected requirements for the assessment and treatment
of patients who had an acute ischemic stroke.f
We reviewed relevant documents, the EHRs of 30 randomly selected patients who experienced stroke symptoms, and 30 employee
training records (5 Emergency Department, 5 medical ICU, 5 surgical ICU, and 15 medical and surgical unit), and we conversed with
key employees. We also conducted onsite inspections of the Emergency Department, two critical care units, and three medical and
surgical units. The table below shows the areas reviewed for this topic. Any items that did not apply to this facility are marked NA. The
facility generally met requirements. We made no recommendations.
NM

Areas Reviewed
The facility’s stroke policy addressed all
required items.
Clinicians completed the National Institutes
of Health stroke scale for each patient within
the expected timeframe.
Clinicians provided medication (tissue
plasminogen activator) timely to halt the
stroke and included all required steps, and
the facility stocked tissue plasminogen
activator in appropriate areas.
Facility managers posted stroke guidelines in
all areas where patients may present with
stroke symptoms.
Clinicians screened patients for difficulty
swallowing prior to oral intake of food or
medicine.
Clinicians provided printed stroke education
to patients upon discharge.
The facility provided training to employees
involved in assessing and treating stroke
patients.

Findings

Recommendations

.

VA OIG Office of Healthcare Inspections

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

NM

Areas Reviewed (continued)
The facility collected and reported required
data related to stroke care.
The facility complied with any additional
elements required by VHA or local policy.

VA OIG Office of Healthcare Inspections

Findings

Recommendations

19

 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

Surgical Complexity
The purpose of this review was to determine whether the facility provided selected support services appropriate to their assigned
surgical complexity designation.g
We reviewed relevant documents and the training records of 60 employees, and we conversed with key managers and employees.
The table below shows the areas reviewed for this topic. The areas marked as NM did not meet applicable requirements and needed
improvement. Any items that did not apply to this facility are marked NA.
NM
X

X

Areas Reviewed
Facility policy defined appropriate availability
for all support services required by VHA for
the facility’s surgical designation.
Employees providing selected tests and
patient care after operational hours had
appropriate competency assessments and
validation.

Findings
 Radiology Service’s policy did not clearly
specify that employees on call for
computed tomography scans and MRI
must report within 30 minutes.
 Two of the three applicable employees on
the surgical ICU did not have
post-anesthesia care competency
assessment and validation documentation
completed.

Recommendations
7. We recommended that Radiology Service
revise the computed tomography scan and
magnetic resonance imaging on-call policy to
require a 30-minute reporting time.
8. We recommended that facility managers
ensure post-anesthesia care competency
assessment and validation is completed for
employees on the surgical intensive care
unit.

The facility properly reported surgical
procedures performed that were beyond the
facility’s surgical complexity designation.
 The facility reviewed and implemented
recommendations made by the VISN Chief
Surgical Consultant
The facility complied with any additional
elements required by VHA or local policy.

VA OIG Office of Healthcare Inspections

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

EAM
The purpose of this review was to determine whether the facility complied with selected VHA out of operating room airway
management requirements.h
We reviewed relevant documents, including competency assessment documentation of 10 clinicians applicable for the review period
January 1 through June 30, 2014, and we conversed with key managers and employees. The table below shows the areas reviewed
for this topic. Any items that did not apply to this facility are marked NA. The facility generally met requirements. We made no
recommendations.
NM

Areas Reviewed
The facility had a local EAM policy or had a
documented exemption.
If the facility had an exemption, it did not
have employees privileged to perform
procedures using moderate or deep sedation
that might lead to airway compromise.
Facility policy designated a clinical subject
matter expert, such as the Chief of Staff or
Chief of Anesthesia, to oversee EAM.
Facility policy addressed key VHA
requirements, including:
 Competency assessment and
reassessment processes
 Use of equipment to confirm proper
placement of breathing tubes
 A plan for managing a difficult airway
Initial competency assessment for EAM
included:
 Subject matter content elements and
completion of a written test
 Successful demonstration of procedural
skills on airway simulators or mannequins
 Successful demonstration of procedural
skills on patients

VA OIG Office of Healthcare Inspections

Findings

Recommendations

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

NM

Areas Reviewed (continued)
Reassessments for continued EAM
competency were completed at the time of
renewal of privileges or scope of practice
and included:
 Review of clinician-specific EAM data
 Subject matter content elements and
completion of a written test
 Successful demonstration of procedural
skills on airway simulators or mannequins
 At least one occurrence of successful
airway management and intubation in the
preceding 2 years, written certification of
competency by the supervisor, or
successful demonstration of skills to the
subject matter expert
 A statement related to EAM if the clinician
was not a licensed independent
practitioner
The facility had a clinician with EAM
privileges or scope of practice available
during all hours the facility provided patient
care.
Video equipment to confirm proper
placement of breathing tubes was available
for immediate clinician use.
The facility complied with any additional
elements required by VHA or local policy.

VA OIG Office of Healthcare Inspections

Findings

Recommendations

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

MH RRTP
The purpose of this review was to determine whether the facility’s Domiciliary Care for Homeless Veterans and the Post-Traumatic
Stress Disorder Programs complied with selected EOC requirements.i
We reviewed relevant documents, inspected the Domiciliary Care for Homeless Veterans and the Post-Traumatic Stress Disorder
Programs, and conversed with key employees. The table below shows the areas reviewed for this topic. The area marked as NM did
not meet applicable requirements and needed improvement. Any items that did not apply to this facility are marked NA.
NM

X

Areas Reviewed
The residential environment was clean and
in good repair.
Appropriate fire extinguishers were available
near grease producing cooking devices.
There were policies/procedures that
addressed safe medication management
and contraband detection.
MH RRTP employees conducted and
documented monthly MH RRTP
self-inspections that included all required
elements, submitted work orders for items
needing repair, and ensured correction of
any identified deficiencies.
MH RRTP employees conducted and
documented contraband inspections, rounds
of all public spaces, daily bed checks, and
resident room inspections for unsecured
medications.
The MH RRTP had written agreements in
place acknowledging resident responsibility
for medication security.
MH RRTP main point(s) of entry had keyless
entry and closed circuit television monitoring,
and all other doors were locked to the
outside and alarmed.

VA OIG Office of Healthcare Inspections

Findings

 We did not find documentation of any
monthly self-inspections.

Recommendations

9. We recommended that Domiciliary Care
for Homeless Veterans and Post-Traumatic
Stress Disorder Program employees conduct
and document monthly self-inspections and
that program managers monitor compliance.

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

NM

Areas Reviewed (continued)
The MH RRTP had closed circuit television
monitors with recording capability in public
areas but not in treatment areas or private
spaces and signage alerting veterans and
visitors of recording.
There was a process for responding to
behavioral health and medical emergencies,
and MH RRTP employees could articulate
the process.
In mixed gender MH RRTP units, women
veterans’ rooms had keyless entry or door
locks, and bathrooms had door locks.
Residents secured medications in their
rooms.
The facility complied with any additional
elements required by VHA or local policy.

VA OIG Office of Healthcare Inspections

Findings

Recommendations

24

 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH
Appendix A

Facility Profile (Cincinnati/539) FY 20141
Type of Organization
Complexity Level
Affiliated/Non-Affiliated
Total Medical Care Budget in Millions
Number of:
 Unique Patients
 Outpatient Visits
 Unique Employees2
Type and Number of Operating Beds (as of August):
 Hospital
 CLC
 MH
Average Daily Census (as of August):
 Hospital
 CLC
 MH
Number of Community Based Outpatient Clinics
Location(s)/Station Number(s)

VISN Number

1
2

Tertiary
1b-High complexity
Affiliated
$375.1
43,412
597,989
1,902
117
64
107
85
50
93
6
Bellevue/539GA
Clermont County/539GB
Lawrenceburg
(Dearborn)/539GC
Florence/539GD
Hamilton/539GE
Georgetown/539GF
10

All data is for the entire FY except where noted. 

Unique employees involved in direct medical care (cost center 8200) from most recent pay period. 


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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH
Appendix B

Strategic Analytics for Improvement and Learning (SAIL)3

3

Metric definitions follow the graphs.

VA OIG Office of Healthcare Inspections

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

Scatter Chart 


FY2014Q3 Quintile

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

Metric Definitions
Measure

Definition

Desired direction

ACSC Hospitalization

Ambulatory care sensitive condition hospitalizations (observed to expected ratio)

A lower value is better than a higher value

Adjusted LOS

Acute care risk adjusted length of stay

A lower value is better than a higher value

Best Place to Work

Overall satisfaction with job

A higher value is better than a lower value

Call Center Responsiveness

Average speed of call center responded to calls in seconds

A lower value is better than a higher value

Call Responsiveness

Call center speed in picking up calls and telephone abandonment rate

A lower value is better than a higher value

Complications

Acute care risk adjusted complication ratio

A lower value is better than a higher value

Efficiency

Overall efficiency measured as 1 divided by SFA (Stochastic Frontier Analysis)

A higher value is better than a lower value

Employee Satisfaction

Overall satisfaction with job

A higher value is better than a lower value

HC Assoc Infections

Health care associated infections

A lower value is better than a higher value

HEDIS

Outpatient performance measure (HEDIS)

A higher value is better than a lower value

MH Status

MH status (outpatient only, the Veterans RAND 12 Item Health Survey)

A higher value is better than a lower value

MH Wait Time

MH wait time for new and established patients (top 50 clinics; FY13 and later)

A higher value is better than a lower value

Oryx

Inpatient performance measure (ORYX)

A higher value is better than a lower value

Physical Health Status

Physical health status (outpatient only, the Veterans RAND 12 item Health Survey)

A higher value is better than a lower value

Primary Care Wait Time

Primary care wait time for new and established patients (top 50 clinics; FY13 and later)

A higher value is better than a lower value

PSI

Patient safety indicator (observed to expected ratio)

A lower value is better than a higher value

Pt Satisfaction

Overall rating of hospital stay (inpatient only)

A higher value is better than a lower value

RN Turnover

Registered nurse turnover rate

A lower value is better than a higher value

RSMR-AMI

30-day risk standardized mortality rate for acute myocardial infarction

A lower value is better than a higher value

RSMR-CHF

30-day risk standardized mortality rate for congestive heart failure

A lower value is better than a higher value

RSMR-Pneumonia

30-day risk standardized mortality rate for pneumonia

A lower value is better than a higher value

RSRR-AMI

30-day risk standardized readmission rate for acute myocardial infarction

A lower value is better than a higher value

RSRR-CHF

30-day risk standardized readmission rate for congestive heart failure

A lower value is better than a higher value

RSRR-Pneumonia

30-day risk standardized readmission rate for pneumonia

A lower value is better than a higher value

SMR

Acute care in-hospital standardized mortality ratio

A lower value is better than a higher value

SMR30

Acute care 30-day standardized mortality ratio

A lower value is better than a higher value

Specialty Care Wait Time

Specialty care wait time for new and established patients (top 50 clinics; FY13 and later)

A higher value is better than a lower value

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH
Appendix C

VISN Director Comments

Department of
Veterans Affairs
Date:
From:
Subject:
To:

Memorandum

January 7, 2015
Director, VA Healthcare System of Ohio (10N10)
CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH
Director, Washington, DC, Office of Healthcare Inspections (54DC)
Director, Management Review Service (VHA 10AR MRS OIG CAP
CBOC)

1. I have reviewed the recommendations and concur with responses and
action plans submitted by the Cincinnati VA Medical Center.
2. If you have questions or require additional information, please
contact Ms. Jane Johnson, VISN 10 Acting Deputy Network Director at
(513) 247-4631.
(original signed by:)

Jack G. Hetrick, FACHE 

Director, VA Healthcare System of Ohio (10N10) 


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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH
Appendix D

Acting Facility Director Comments

Department of
Veterans Affairs
Date:
From:
Subject:
To:

Memorandum

January 7, 2015
Acting Director, Cincinnati VA Medical Center (539/00)
CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH
Director, Washington, DC, Office of Healthcare Inspections (54DC)

1. Attached please find the Cincinnati VA Medical Center responses and
relevant action plan for the 9 recommendations from the Office of the
Inspector General Combined Assessment Program Review conducted
October 20–24, 2014.
2. We appreciate the professionalism demonstrated by the OIG CAP
Team and the consultative attitude demonstrated during the review
process.
3. If you have any questions regarding this report, please contact
Lisa Veite, Cincinnati VA Medical Center Accreditation Specialist, at
513-861-3100, extension 5249.
(original signed by:)

Acting Director David Ninneman

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

Comments to OIG’s Report
The following Director’s comments are submitted in response to the recommendations
in the OIG report:
OIG Recommendations
Recommendation 1.
We recommended that the facility ensure that licensed

independent practitioners’ folders do not contain licensure verification information. 

Concur

Target date for completion: 1/16/2015 

Facility response: Licensure verification will no longer be maintained in independent 

practitioners’ folders. All licensure verifications will be removed from each independent

practitioner’s folder. 

Recommendation 2. We recommended that the facility store clean and dirty items

separately and that facility managers monitor compliance. 

Concur

Target date for completion: 4/30/2015 

Facility response: The shower litter was removed from the CLC. Dirty equipment has

been removed from clean storage areas. Clean and dirty items are being stored 

separately. Compliance will be monitored by designated CLC and 6N managers. 

Recommendation 3. We recommended that the facility appropriately protect computer 

monitors from public viewing on the medical and surgical units and that facility

managers monitor compliance.

Concur

Target date for completion: 4/30/2015 

Facility response: An inventory has been taken on the medical and surgical units for 

needed privacy screens and an order is in process. The privacy screens will be 

installed on the monitors once the order is received. Compliance will be monitored by

the facility Privacy Officer. 


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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

Recommendation 4. We recommended that the facility revise the policy for safe use of
automated dispensing machines to include employee training and minimum
competency requirements for users and that facility manager’s monitor compliance.
Concur
Target date for completion: 12/23/2014
Facility response: An addendum to the Automated Dispensing System (ADS) Policy
and Procedure was completed and communicated 12/23/2014 stating that all users will
be trained on the use of the ADS as part of the orientation process. Competency will be
assessed by the supervisors through the existing monitoring of ADS reports for
inappropriate or inconsistent use by users.
Recommendation 5. We recommended that the facility designate a committee to
oversee consult management.
Concur
Target date for completion: 12/23/2014
Facility response: The Accelerated Care Initiative Committee has been designated to
oversee consult management. This committee was initiated and began oversight of
consult management October 14, 2014 as part of their charge. The committee meets
monthly.
Recommendation 6.
We recommended that the Automated Data Processing
Applications Coordinators provide training in the use of the computerized consult
package and that facility managers monitor compliance.
Concur
Target date for completion: 6/30/2015
Facility response: The Office of Information Technology (OIT) will coordinate training
with Automated Data Processing Application Coordinators in the use of computerized
consult package. Compliance will be monitored by the OIT manager.
Recommendation 7. We recommended that Radiology Service revise the computed
tomography scan and magnetic resonance imaging on-call policy to require a 30-minute
reporting time.
Concur
Target date for completion: 1/7/2015
Facility response: Radiology revised the on-call process to incorporate a 30 minute
reporting time for computed tomography scan and magnetic resonance. Radiology also

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

developed a Standard Operating Procedure (SOP) entitled Radiology On Call and Call
Back which incorporates the required 30-minute reporting time.
Recommendation 8. We recommended that facility managers ensure post-anesthesia
care competency assessment and validation is completed for employees on the surgical
intensive care unit.
Concur
Target date for completion: 1/5/2015
Facility response: All twenty-one employees in the surgical intensive care unit
who have completed orientation have completed the post-anesthesia care
competency assessment and validation. The Surgical Intensive Care Unit skill
assessment/verification orientation record has been revised with specific
post-anesthesia care skill assessments included.
Recommendation 9. We recommended that Domiciliary Care for Homeless Veterans
and Post-Traumatic Stress Disorder Program employees conduct and document
monthly self-inspections and that program managers monitor compliance.
Concur
Target date for completion: 3/31/2015
Facility response: As of October 31, 2014 the Domiciliary Care of Homeless Veterans
and the Post Traumatic Stress Disorder programs are conducting and documenting
monthly self-inspection. Compliance will be monitored by the Nurse Manager at the
Ft. Thomas division.

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH
Appendix E

Office of Inspector General
Contact and Staff Acknowledgments
Contact
Inspection Team

Other
Contributors

For more information about this report, please contact the OIG
at (202) 461-4720.
Gail Bozzelli, RN, Team Leader
Bruce Barnes
Myra Conway, RN
Kay Foster, RN
Donna Giroux, RN
Laura Snow, LCSW
Randall Snow, JD
Elizabeth Bullock
Shirley Carlile, BA
Paula Chapman, CTRS
Lin Clegg, PhD
Marnette Dhooghe, MS
Natalie Sadow, MS
Patrick Smith, M. Stat
Julie Watrous, RN, MS
Jarvis Yu, MS

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH
Appendix F

Report Distribution
VA Distribution
Office of the Secretary
Veterans Health Administration
Assistant Secretaries
General Counsel
Director, VA Healthcare System of Ohio (10N10)
Acting Director, Cincinnati VA Medical Center (539/00)
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: Sherrod Brown, Daniel Coats, Joe Donnelly, Mitch McConnell, Rand Paul,
Rob Portman
U.S. House of Representatives: John A. Boehner, Steve Chabot, Thomas Massie,
Luke Messer, Brad Wenstrup

This report is available at www.va.gov/oig.

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH
Appendix G

Endnotes
a

References used for this topic included:

  VHA Directive 1026, VHA Enterprise Framework for Quality, Safety, and Value, August 2, 2013.
  VHA Handbook 1050.01, VHA National Patient Safety Improvement Handbook, March 4, 2011.
  VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010.
  VHA Directive 2010-032, Safe Patient Handling Program and Facility Design, June 28, 2010.
  VHA Directive 1036, Standards for Observation in VA Medical Facilities, February 6, 2014.
  VHA Handbook 1100.19, Credentialing and Privileging, October 15, 2012.
  VHA Handbook 1102.01, National Surgery Office, January 30, 2013.
  VHA Directive 2008-063, Oversight and Monitoring of Cardiopulmonary Resuscitative Events and Facility

Cardiopulmonary Resuscitation Committees, October 17, 2008.
  VHA Handbook 1907.01, Health Information Management and Health Records, July 22, 2014.
b

References used for this topic included:

  VHA Directive 2010-052, Management of Wandering and Missing Patients, December 3, 2010.
  VHA Directive 2011-007, Required Hand Hygiene Practices, February 16, 2011.
  Under Secretary for Health, “Non- Research Animals in Health Care Facilities,” Information Letter 10-2009-007,

June 11, 2009.
  Various requirements of The Joint Commission, the Occupational Safety and Health Administration, the

International Association of Healthcare Central Service Materiel Management, the National Fire Protection
Association, the Health Insurance Portability and Accountability Act, Underwriters Laboratories.
c
References used for this topic included:
  VHA Directive 2008-027, The Availability of Potassium Chloride for Injection Concentrate USP, May 13, 2008.
  VHA Directive 2010-020, Anticoagulation Therapy Management, May 14, 2010.
  VHA Handbook 1108.01, Controlled Substances (Pharmacy Stock), November 16, 2010.
  VHA Handbook 1108.05, Outpatient Pharmacy Services, May 30, 2006.
  VHA Handbook 1108.06, Inpatient Pharmacy Services, June 27, 2006.
  VHA Handbook 1108.07, Pharmacy General Requirements, April 17, 2008.
  Various requirements of The Joint Commission.
d
The reference used for this topic was:
  Under Secretary for Health, “Consult Business Rule Implementation,” memorandum, May 23, 2013.
e
References used for this topic included:
  VHA Handbook 1105.05, Magnetic Resonance Imaging Safety, July 19, 2012.
  Emanuel Kanal, MD, et al., “ACR Guidance Document on MR Safe Practices: 2013,” Journal of Magnetic
Resonance Imaging, Vol. 37, No. 3, January 23, 2013, pp. 501–530.
  The Joint Commission, “Preventing accidents and injuries in the MRI suite,” Sentinel Event Alert, Issue 38,
February 14, 2008.
  VA National Center for Patient Safety, “MR Hazard Summary,”
http://www.patientsafety.va.gov/professionals/hazards/mr.asp.
  VA Radiology, “Online Guide,” http://vaww1.va.gov/RADIOLOGY/OnLine_Guide.asp, updated
October 4, 2011.
f
The references used for this topic were:
  VHA Directive 2011-038, Treatment of Acute Ischemic Stroke, November 2, 2011.
  Guidelines for the Early Management of Patients with Acute Ischemic Stroke (AHA/ASA Guidelines),
January 31, 2013.
g
 References used for this topic included:
  VHA Directive 2009-001, Restructuring of VHA Clinical Programs, January 5, 2009.
  VHA Directive 2010-018, Facility Infrastructure Requirements to Perform Standard, Intermediate, or Complex
Surgical Procedures, May 6, 2010. 
h
References used for this topic included:
  VHA Directive 2012-032, Out of Operating Room Airway Management, October 26, 2012.
  VHA Handbook 1101.04, Medical Officer of the Day, August 30, 2010.

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 CAP Review of the Cincinnati VA Medical Center, Cincinnati, OH

i

References used for this topic were: 


 VHA Handbook 1162.02, Mental Health Residential Rehabilitation Treatment Program (MH RRTP), 


December 22, 2010.
  VHA Handbook 1330.01, Health Care Services for Women Veterans, May 21, 2010.
  Requirements of the VHA Center for Engineering and Occupational Safety and Health and the National Fire

Protection Association.

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