Combined Assessment Program Review of The Grand Junction VA Medical Center Grand Junction, Colorado

Department of Veterans Affairs
Office of Inspector General

Office of Healthcare Inspections
Report No. 14-02068-264
Combined Assessment Program
Review of the
Grand Junction VA Medical Center
Grand Junction, Colorado
September 2, 2014
Washington, DC 20420

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

CAP Review of the Grand J unction VA Medical Center, Grand J unction, CO
Glossary
AIS acute ischemic stroke
CAP Combined Assessment Program
CLC community living center
CRC colorectal cancer
ED emergency department
EHR electronic health record
EOC environment of care
facility Grand J unction VA Medical Center
FY fiscal year
MEC Medical Executive Committee
MH mental health
MRI magnetic resonance imaging
NA not applicable
NM not met
OIG Office of Inspector General
PACU post-anesthesia care unit
PRC Peer Review Committee
QM quality management
SDS same day surgery
tPA tissue plasminogen activator
VHA Veterans Health Administration
VISN Veterans Integrated Service Network
VA OIG Office of Healthcare Inspections

Table of Contents
Page
Executive Summary ................................................................................................... i
Objectives and Scope ................................................................................................ 1
Objectives ............................................................................................................... 1
Scope...................................................................................................................... 1
Results and Recommendations ................................................................................ 3
QM .......................................................................................................................... 3
EOC ........................................................................................................................ 6
Medication Management......................................................................................... 8
Coordination of Care ............................................................................................... 9
AIS Care ................................................................................................................. 10
CLC Resident Independence and Dignity ............................................................... 12
MRI Safety .............................................................................................................. 14
Review Activity with Previous CAP Recommendations ......................................... 16
Follow-Up on CRC Screening ................................................................................. 16
Appendixes
A. Facility Profile .................................................................................................... 17
B. Strategic Analytics for Improvement and Learning ............................................ 18
C. Acting VISN Director Comments ....................................................................... 21
D. Facility Director Comments ............................................................................... 22
E. OIG Contact and Staff Acknowledgments ......................................................... 29
F. Report Distribution ............................................................................................. 30
G. Endnotes ........................................................................................................... 31
VA OIG Office of Healthcare Inspections

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 J uly 7, 2014.
Review Results: The review covered seven activities and one follow-up review area
from the previous Combined Assessment Program review. We made no
recommendations in the following two activities:
Medication Management
Coordination of Care
Recommendations: We made recommendations in the following five activities and
follow-up area:
Quality Management: Ensure the Medical Executive Committee discusses and
documents its approval of the use of another facilitys providers for teledermatology
services. Consistently perform continuing stay reviews on at least 75 percent of
patients in acute beds. Review the quality of entries in the electronic health record.
Ensure the Blood Usage Review Committee member from Anesthesia Service
consistently attends meetings.
Environment of Care: Install nurse call system alarms in the emergency department.
Date multi-dose medication vials when opened, and promptly remove expired
medications from patient care areas.
Acute Ischemic Stroke Care: Develop an acute ischemic stroke policy that addresses
all required items, and fully implement the policy. Complete and document National
Institutes of Health stroke scales for each stroke patient. Post stroke guidelines in the
emergency department, on the critical care unit, and on all inpatient units. Screen
patients for difficulty swallowing prior to oral intake, and provide printed stroke education
to patients upon discharge. Collect and report to the Veterans Health Administration the
percent of eligible patients given tissue plasminogen activator, the percent of patients
with stroke symptoms who had the stroke scale completed, and the percent of patients
screened for difficulty swallowing before oral intake.
Community Living Center Resident Independence and Dignity: Ensure the Restorative
Care Coordinator documents patient restorative program goals and progress weekly in
accordance with facility policy.
Magnetic Resonance Imaging Safety: Complete initial patient safety screenings, and
document them in patients electronic health records. Complete secondary patient
safety screenings immediately prior to magnetic resonance imaging, and place them in
patients electronic health records. Identify any contraindications, and document
VA OIG Office of Healthcare Inspections i

resolution prior to magnetic resonance imaging. Ensure Level 2 personnel conducting
secondary screenings sign the forms prior to the scan.
Follow-Up on Colorectal Cancer Screening: Implement processes to monitor
compliance with colorectal cancer timeliness and patient notification requirements.
Comments
The Acting Veterans Integrated Service Network Director and Facility Director agreed
with the Combined Assessment Program review findings and recommendations and
provided acceptable improvement plans. (See Appendixes C and D, pages 2128, for
the full text of the Directors comments.) We will follow up on the planned actions until
they are completed.
J OHN D. DAIGH, J R., M.D.
Assistant Inspector General for
Healthcare Inspections
VA OIG Office of Healthcare Inspections ii

Objectives and Scope
Objectives
CAP reviews are one element of the OIGs efforts to ensure that our Nations 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 seven activities and follow-up review area from the previous CAP review:
QM
EOC
AIS Care
CLC Resident Independence and Dignity
MRI Safety
Follow-Up on CRC Screening
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 1

The review covered facility operations for FY 2012, FY 2013, and FY 2014 through
J uly 7, 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
Grand Junction VA Medical Center, Grand Junction, Colorado, Report No. 11-03657-62,
J anuary 12, 2012). We made a recommendation in CRC Screening.
During this review, we presented crime awareness briefings for 90 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
228 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.

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, EHRs, and other relevant documents. 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 Findings
There was a senior-level committee/group
responsible for QM/performance improvement
that met regularly.
There was evidence that outlier data was
acted upon.
There was evidence that QM, patient
safety, and systems redesign were
integrated.
The protected peer review process met
selected requirements:
The PRC was chaired by the Chief of Staff
and included membership by applicable
service chiefs.
Actions from individual peer reviews were
completed and reported to the PRC.
The PRC submitted quarterly summary
reports to the MEC.
Unusual findings or patterns were
discussed at the MEC.
Focused Professional Practice Evaluations for
newly hired licensed independent practitioners
were initiated and completed, and results
were reported to the MEC.
X Specific telemedicine services met selected
requirements:
Services were properly approved.
Services were provided and/or received by
appropriately privileged staff.
Professional practice evaluation information
was available for review.
Twelve months of MEC meeting minutes
reviewed:
There was no evidence that the MEC had
approved the use of telemedicine technology
for teledermatology services.

NM Areas Reviewed (continued) Findings
Observation bed use met selected
requirements:
Local policy included necessary elements.
Data regarding appropriateness of
observation bed usage was gathered.
If conversions to acute admissions were
consistently 30 percent or more,
observation criteria and utilization were
reassessed timely.
X Staff performed continuing stay reviews on at
least 75 percent of patients in acute beds.
Twelve months of continuing stay data reviewed:
For 9 months, less than 75 percent of acute
inpatients were reviewed.
The process to review resuscitation events
met selected requirements:
An interdisciplinary committee was
responsible for reviewing 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.
Data were collected that measured
performance in responding to events.
The surgical review process met selected
requirements:
An interdisciplinary committee with
appropriate leadership and clinical
membership met monthly to review surgical
processes and outcomes.
Surgical deaths with identified problems or
opportunities for improvement were
reviewed.
Additional data elements were routinely
reviewed.
Critical incidents reporting processes were
appropriate.
X The process to review the quality of entries in
the EHR met selected requirements:
A committee was responsible to review
EHR quality.
Data were collected and analyzed at least
quarterly.
Reviews included data from most services
and program areas.
There was no evidence that the quality of
entries in the EHR was reviewed.
The policy for scanning non-VA care
documents met selected requirements.

X The process to review blood/transfusions
usage met selected requirements:
A committee with appropriate clinical
membership met at least quarterly to review
blood/transfusions usage.
Additional data elements were routinely
reviewed.
Twelve months of Blood Usage Review
Committee meeting minutes reviewed:
The clinical representative from Anesthesia
Service attended only two of four meetings.
Overall, if significant issues were identified,
actions were taken and evaluated for
effectiveness.
Overall, senior managers were involved in
performance improvement over the past
12 months.
Overall, the facility had a comprehensive,
effective QM/performance improvement
program over the past 12 months.
The facility met any additional elements
required by VHA or local policy.
Recommendations
1. We recommended that the Medical Executive Committee discuss and document its
approval of the use of another facilitys providers for teledermatology services.
2. We recommended that processes be strengthened to ensure that continuing stay reviews
are consistently performed on at least 75 percent of patients in acute beds.
3. We recommended that processes be strengthened to ensure that the quality of entries in
the electronic health record is reviewed.
4. We recommended that processes be strengthened to ensure that the Blood Usage Review
Committee member from Anesthesia Service consistently attends meetings.

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 and whether the facility
met selected requirements in SDS, the PACU, and the eye clinic.
b
We inspected the intensive care unit, two medical/surgical units, the MH unit, the ED, the CLC,
SDS, the operating room, and the PACU. Additionally, we reviewed relevant documents,
conversed with key employees and managers, and reviewed 19 employee training records
(4 SDS, 10 operating room, and 5 PACU). The table below shows the areas reviewed for this
topic. The areas marked as NM did not meet applicable requirements and needed
NM Areas Reviewed for General EOC Findings
EOC Committee minutes reflected sufficient
detail regarding identified deficiencies,
corrective actions taken, and tracking of
corrective actions to closure.
An infection prevention risk assessment was
conducted, and actions were implemented to
address high-risk areas.
Infection Prevention/Control Committee
minutes documented discussion of identified
problem areas and follow-up on implemented
actions and included analysis of surveillance
activities and data.
Fire safety requirements were met.
X Environmental safety requirements were met. We did not find nurse call systems in one of
six patient care areas.
Infection prevention requirements were met.
X Medication safety and security requirements
were met.
We found open, expired multi-dose
medication vials in two of six patient care
areas.
Auditory privacy requirements were met.
The facility complied with any additional
elements required by VHA, local policy, or
other regulatory standards.
Areas Reviewed for SDS and the PACU
Designated SDS and PACU employees
received bloodborne pathogens training
during the past 12 months.
Designated SDS employees received medical
laser safety training with the frequency
required by local policy.
Fire safety requirements in SDS and on the
PACU were met.
Environmental safety requirements in SDS
and on the PACU were met.

NM Areas Reviewed for SDS and the PACU
(continued)
Findings
SDS medical laser safety requirements were
met.
Infection prevention requirements in SDS and
on the PACU were met.
X Medication safety and security requirements
in SDS and on the PACU were met.
We found an open, unlabeled multi-dose
medication vial in one of two patient care
areas.
Auditory privacy requirements in SDS and on
the PACU were met.
Areas Reviewed for Eye Clinic
NA Designated eye clinic employees received
laser safety training with the frequency
required by local policy.
NA Environmental safety requirements in the eye
clinic were met.
NA Infection prevention requirements in the eye
clinic were met.
NA Medication safety and security requirements
in the eye clinic were met.
NA Laser safety requirements in the eye clinic
were met.
NA The facility complied with any additional
Recommendations
5. We recommended that nurse call systems be installed in the emergency department.
6. We recommended that processes be strengthened to ensure that multi-dose medication
vials are dated when opened and expired medications are promptly removed from patient care
areas and that compliance be monitored.

The purpose of this review was to determine whether the appropriate clinical oversight and
education were provided to patients discharged with orders for fluoroquinolone oral antibiotics.
c
We reviewed relevant documents and conversed with key managers and employees.
Additionally, we reviewed the EHRs of 32 randomly selected inpatients discharged
on 1 of 3 selected oral antibiotics. 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.
Clinicians conducted inpatient learning
assessments within 24 hours of admission or
earlier if required by local policy.
If learning barriers were identified as part of
the learning assessment, medication
counseling was adjusted to accommodate the
barrier(s).
Patient renal function was considered in
fluoroquinolone dosage and frequency.
Providers completed discharge progress
notes or discharge instructions, written
instructions were provided to
patients/caregivers, and EHR documentation
reflected that the instructions were
understood.
Patients/caregivers were provided a written
medication list at discharge, and the
information was consistent with the dosage
and frequency ordered.
Patients/caregivers were offered medication
counseling, and this was documented in
patient EHRs.
The facility established a process for
patients/caregivers regarding whom to notify
in the event of an adverse medication event.
elements required by VHA or local policy.

The purpose of this review was to evaluate discharge planning for patients with selected
aftercare needs.
d
We reviewed relevant documents and conversed with key employees. Additionally,
we reviewed the EHRs of two patients with specific diagnoses who were discharged from
J uly 1, 2012, through J une 30, 2013. 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.
Patients post-discharge needs were identified,
and discharge planning addressed the
identified needs.
Clinicians provided discharge instructions to
patients and/or caregivers and validated their
understanding.
Patients received the ordered aftercare
services and/or items within the
ordered/expected timeframe.
Patients and/or caregivers knowledge and
learning abilities were assessed during the
inpatient stay.

AIS 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 AIS.
e
We reviewed relevant documents and the EHRs of 12 patients who experienced stroke
symptoms, and we conversed with key employees. We also conducted onsite inspections of the
ED, one critical care unit, and four inpatient units. The table below shows the areas reviewed
for this topic. The areas marked as NM did not meet applicable requirements and needed
X The facilitys stroke policy/plan/guideline
addressed all required items.
The facility did not have a policy in place
addressing the management of AIS.
X Clinicians completed the National Institutes of
Health stroke scale for each patient within the
expected timeframe.
None of the EHRs contained documented
evidence of completed stroke scales.
NA Clinicians provided medication (tPA) timely to
halt the stroke and included all required steps,
and tPA was in stock or available within
15 minutes.
X Stroke guidelines were posted in all areas
where patients may present with stroke
symptoms.
Stroke guidelines were not posted in the ED
or on any of the five units.
X Clinicians screened patients for difficulty
swallowing prior to oral intake of food or
medicine.
Five of the 11 applicable EHRs did not
contain documentation that patients were
screened for difficulty swallowing prior to oral
intake.
X Clinicians provided printed stroke education to
patients upon discharge.
Eight of the 10 applicable EHRs did not
contain documentation that stroke education
was provided to the patient/caregiver.
NA The facility provided training to staff involved
in assessing and treating stroke patients.
X The facility collected and reported required
data related to stroke care.
There was no evidence that the following data
were collected and/or reported to VHA:
o Percent of eligible patients given tPA
o Percent of patients with stroke symptoms
who had the stroke scale completed
o Percent of patients screened for difficulty
swallowing before oral intake.
Recommendations
7. We recommended that the facility develop an acute ischemic stroke policy that addresses
all required items, that the policy be fully implemented, and that compliance be monitored.

8. We recommended that processes be strengthened to ensure that clinicians complete and
document National Institutes of Health stroke scales for each stroke patient and that compliance
be monitored.
9. We recommended that stroke guidelines be posted in the emergency department, on the
critical care unit, and on all inpatient units.
10. We recommended that processes be strengthened to ensure that clinicians screen patients
for difficulty swallowing prior to oral intake.
11. We recommended that processes be strengthened to ensure that clinicians provide printed
stroke education to patients upon discharge and that compliance be monitored.
12. We recommended that the facility collect and report to VHA the percent of eligible patients
given tissue plasminogen activator, the percent of patients with stroke symptoms who had the
stroke scale completed, and the percent of patients screened for difficulty swallowing before oral
intake.

CLC Resident Independence and Dignity
The purpose of this review was to determine whether the facility provided CLC restorative
nursing services and complied with selected nutritional management and dining service
requirements to assist CLC residents in maintaining their optimal level of functioning,
independence, and dignity.
f
We reviewed six EHRs of residents (five residents receiving restorative nursing services and
one resident not receiving restorative nursing services but a candidate for services).
We also observed one resident during two meal periods, reviewed two employee
training/competency records and other relevant documents, 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.
The facility offered restorative nursing
services.
Facility staff completed and documented
restorative nursing services, including active
and passive range of motion, bed mobility,
transfer, and walking activities, according to
clinician orders and residents care plans.
Resident progress towards restorative nursing
goals was documented, and interventions
were modified as needed to promote the
residents accomplishment of goals.
When restorative nursing services were care
planned but were not provided or were
discontinued, reasons were documented in
the EHR.
If residents were discharged from physical
therapy, occupational therapy, or
kinesiotherapy, there was hand-off
communication between Physical Medicine
and Rehabilitation Service and the CLC to
ensure that restorative nursing services
occurred.
Training and competency assessment were
completed for staff who performed restorative
nursing services.
X The facility complied with any additional
Facility policy on CLC Restorative Nursing
Program reviewed:
The Restorative Care Coordinator did not
consistently document patient restorative
program goals and progress weekly in any of
the five applicable EHRs.

NM Areas Reviewed for Assistive Eating
Devices and Dining Service
Findings
Care planned/ordered assistive eating devices
were provided to residents at meal times.
Required activities were performed during
resident meal periods.
Recommendation
13. We recommended that processes be strengthened to ensure that the Restorative Care
Coordinator documents patient restorative program goals and progress weekly in accordance
with facility policy and that compliance be monitored.

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.
g
We reviewed relevant documents and the training records of 32 employees (28 randomly
selected Level 1 ancillary staff and 4 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 J anuary 1December 31, 2013. Additionally, we conducted a physical
inspection of one MRI area. 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.
The facility completed an MRI risk
assessment, there were documented
procedures for handling emergencies in MRI,
and emergency drills were conducted in the
MRI area.
X Two patient safety screenings were conducted
prior to MRI, and the secondary patient safety
screening form was signed by the patient,
family member, or caregiver and reviewed and
signed by a Level 2 MRI personnel.
None of the EHRs contained initial patient
safety screenings.
Thirty-three EHRs (94 percent) did not contain
secondary patient safety screenings prior to
MRI; therefore, we were unable to determine
whether any contraindications were
addressed.
Neither of the two secondary patient safety
screening forms were signed by a Level 2
MRI personnel prior to MRI.
Any MRI contraindications were noted on the
secondary patient safety screening form, and
a Level 2 MRI personnel and/or radiologist
addressed the contraindications and
documented resolution prior to MRI.
Level 1 ancillary staff and Level 2 MRI
personnel were designated and received
level-specific annual MRI safety training.
Signage and barriers were 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 two-way communication
device was regularly tested.
Patients were offered MRI-safe hearing
protection for use during the scan.

The facility had only MRI-safe or compatible
equipment in Zones III and IV, or the
equipment was appropriately protected from
the magnet.
Recommendations
14. We recommended that processes be strengthened to ensure that initial patient safety
screenings are conducted and documented in patients electronic health records and that
compliance be monitored.
15. We recommended that processes be strengthened to ensure that secondary patient safety
screenings are completed immediately prior to magnetic resonance imaging and placed in
patients electronic health records, that any contraindications are identified and resolution
documented prior to the scan, that Level 2 personnel conducting the secondary screenings sign
the forms prior to the scan, and that compliance be monitored.

Review Activity with Previous CAP Recommendations
Follow-Up on CRC Screening
As a follow-up to recommendations from our previous CAP review, we attempted to reassess
facility compliance with CRC screening;
h
however, the facility was unable to provide evidence of
sustained compliance for any of the requirements below.
Positive CRC Screening Test Result Notification. VHA requires that patients receive notification
of CRC screening test results within 14 days of the laboratory receipt date for fecal occult blood
tests or the test date for sigmoidoscopy or double contrast barium enema and that clinicians
document notification.
Follow-Up in Response to Positive CRC Screening Test. For any positive CRC screening test,
VHA requires responsible clinicians to either document a follow-up plan or document that
no follow-up is indicated within 14 days of the screening test.
Diagnostic Testing Timeliness. VHA requires that patients receive diagnostic testing within
60 days of positive CRC screening test results unless contraindicated.
Diagnostic Test Result Notification. VHA requires that test results be communicated to patients
no later than 14 days from the date on which the results are available to the ordering practitioner
and that clinicians document notification.
Biopsy Result Notification. VHA requires that patients who have a biopsy receive notification
within 14 days of the date the biopsy results were confirmed and that clinicians document
notification.
Recommendation
16. We recommended that the facility implement processes to monitor compliance with
colorectal cancer timeliness and patient notification requirements.

Appendix A
Facility Profile (Grand Junction/575) FY 2014 through
June 2014
1
Type of Organization Secondary
Complexity Level 2-Medium complexity
Affiliated/Non-Affiliated Affiliated
Total Medical Care Budget in Millions $98.9
Number (as of July 2014) of:
Unique Patients 13,046
Outpatient Visits 143,021
Unique Employees
2
501
Type and Number of Operating Beds:
Hospital 31
CLC 30
MH NA
Average Daily Census:
Hospital 17
CLC 25
MH NA
Number of Community Based Outpatient Clinics 2
Location(s)/Station Number(s) Montrose/575GA
Craig/575GB
VISN Number 19
1
All data is for FY 2014 through J une 2014 except where noted.
2
Unique employees involved in direct medical care (cost center 8200).

Appendix B
Strategic Analytics for Improvement and Learning (SAIL)
3
3
Metric definitions follow the graphs.

Scatter Chart

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

Appendix C
Acting VISN Director Comments
Department of
Veterans Affairs Memorandum
Date: August 15, 2014
From: Acting Director, Rocky Mountain Network (10N19)
Subject: CAP Review of the Grand Junction VA Medical Center,
Grand Junction, CO
To: Director, Dallas Office of Healthcare Inspections (54DA)
Director, Management Review Service (VHA 10AR MRS
OIG CAP CBOC)
I have reviewed and concur on the submitted responses to the
Grand J unction VAMC OIG CAP Draft Report. If you have any further
questions please contact Ms. Susan Curtis, VISN 19 HSS (303) 639-6995.
Signed for and in the absence of:
Ralph T. Gigliotti, FACHE
Director, Rocky Mountain Network (10N19)

Appendix D
Facility Director Comments
Department of
Veterans Affairs Memorandum
Date: August 11, 2014
From: Director, Grand J unction VA Medical Center (575/00)
Subject: CAP Review of the Grand Junction VA Medical Center,
Grand Junction, CO
To: Director, Rocky Mountain Network (10N19)
1. Thank you for the opportunity to submit responses to the
proposed recommendations for the Grand J unction VA Medical Center,
Grand J unction, CO.
2. I have reviewed and concur with the sixteen (16) findings and
recommendations in the report of the Office of Inspector General
conducted the week of J uly 7, 2014.
3. Corrective action plans and compliance monitoring have been
established and target completion dates have been set for the
recommendations as detailed in the attached report.
4. If you have additional questions or need further information,
please contact Michelle Ernzen, Chief, Quality Management, at
(970) 242-0731, x2873.

Comments to OIGs Report
The following Directors comments are submitted in response to the recommendations
in the OIG report:
OIG Recommendations
Recommendation 1. We recommended that the Medical Executive Committee discuss
and document its approval of the use of another facilitys providers for teledermatology
services.
Concur
Target date for completion: October 31, 2014
Facility response: The teledermatology service agreement will be discussed at the
September Clinical Executive Board meeting. Discussions and approval of services will
be documented in the meeting minutes.
Recommendation 2. We recommended that processes be strengthened to ensure that
continuing stay reviews are consistently performed on at least 75 percent of patients
in acute beds.
Concur
Facility response: The facility hired and trained a Quality Management Specialist
(J anuary 2014) who has primary responsibilities for performing and communicating
continued stay reviews. Additionally, another QM Specialist has been trained to
complete the reviews, thus providing continued coverage during planned and unplanned
absences. Since March 2014, the facility has achieved >95% compliance on the
continued stay reviews. Compliance monitoring will occur quarterly through the UM
report to the Clinical Executive Board.
the quality of entries in the electronic health record is reviewed.
Concur
Target date for completion: J une 30, 2015
Facility response: Service Chiefs, Supervisors, and Administrative Officers received
training on the process for performing quality record reviews and reporting requirements
to the Medical Record Committee. Quality Management developed and distributed a
Microsoft Excel workbook to aid services in compiling and reporting the quality record
reviews to the committee. The Medical Record Committee will develop and distribute a

reporting grid that outlines when services are scheduled to report their quality record
reviews to the committee. Quality data not meeting the identified performance standard
will require action plans for submission to committee for review and analysis.
Compliance will be monitored through the Medical Record Committee.
the Blood Usage Review Committee member from Anesthesia Service consistently
attends meetings.
Concur
Target date for completion: December 31, 2014
Facility response: The Section Chief, Anesthesia, has been assigned as the permanent
member of the Blood Utilization Committee. During his absence, another Anesthesia
provider will attend the meetings.
Recommendation 5. We recommended that nurse call systems be installed in the
emergency department.
Concur
Target date for completion: J une 30, 2015
Facility response: GJ VAMC concurs with the recommendation to install a nurse call
system in the Emergency Department. By December 31, 2014, a request for funding
will be uploaded to the VISN 19 Capital Asset Manager (CAM) for the design and
installation of the nurse call systems. Award of the project is expected by
March 31, 2015. Interim measures are in place and include bedside hand bells and
increased staff presence.
multi-dose medication vials are dated when opened and expired medications
are promptly removed from patient care areas and that compliance be monitored.
Concur
Facility response: By August 31, 2014, the Medication Management Policy
(MCM 119-3) will be revised to reflect the need for expired medications to be promptly
removed from patient care areas. Patient Care Services staff will be re-educated
on the policy and procedures required for safe medication management by
September 30, 2014. Additionally, the expiration date review has been added to the
Daily Checklist for all patient care areas, and as a result, all MDV will be checked for
expiration on a daily basis (on days the unit is open; i.e. Outpatient Clinics that work
MondayFriday will not have the checklist completed on weekends, as there are no
patients or staff in those areas during the weekend). The Associate Chief Nurse

(ACNS) assigned to each unit will be responsible for monitoring compliance via review
of the Daily Checklists. Compliance will also be monitored during EOC rounds.
Recommendation 7. We recommended that the facility develop an acute ischemic
stroke policy that addresses all required items, that the policy be fully implemented, and
that compliance be monitored.
Concur
Facility response: A small interdisciplinary team has been formed and is developing a
policy defining the treatment of Acute Ischemic Stroke (AIS) for a Supporting Stroke
Facility as required by VHA Directive by September 30, 2014. Education of staff will be
completed by October 31, 2014. Compliance monitoring will be accomplished through
the AIS quality indicator monitoring and reported quarterly to the Critical Care
Committee.
clinicians complete and document National Institutes of Health stroke scales for each
stroke patient and that compliance be monitored.
Concur
Target date for completion: March 31, 2015
Facility response: An NIH template note is being developed for documentation of the
NIH stroke scale. The note will be free-standing for clinical staff to complete when
indicated and will be incorporated into the Emergency Department triage note.
The template note and staff training will occur by October 31, 2014.
Compliance monitoring of the use of the NIH stroke scale will be accomplished through
the AIS quality indicator monitoring and reported to the Critical Care Committee.
Recommendation 9. We recommended that stroke guidelines be posted in the
emergency department, on the critical care unit, and on all inpatient units.
Concur
Facility response: Stroke guidelines for recognition and treatment of AIS will be posted
in the outpatient clinics, inpatient wards, Community Living Center, and the Emergency
Department by October 31, 2014. In addition, stroke guideline badge buddies have
been ordered and will be distributed to clinical staff.

Recommendation 10. We recommended that processes be strengthened to ensure
that clinicians screen patients for difficulty swallowing prior to oral intake.
Concur
Facility response: Nursing Patient Care Memorandum 003-50, Stroke Patient Nursing
Swallow Screen has been in place since March 2013. Nursing staff will be re-educated
on the dysphagia screening by October 31, 2014. Compliance monitoring of the
dysphagia screening will be accomplished through the AIS quality indicator monitoring
and reported to the Critical Care Committee.
that clinicians provide printed stroke education to patients upon discharge and that
compliance be monitored.
Concur
Facility response: Education Service will identify select stroke education materials that
will be available for Veterans. Educational material will be added to the tools section in
CPRS so staff can print and provide to patients on discharge. Reminder dialogue will
be added to the Education Note for staff to document the specific handout that was
provided to the Veteran/Caregiver. Training of staff will occur by October 31, 2014.
Compliance monitoring of documentation of printed materials will be accomplished
through the AIS quality indicator monitoring process and reported to the Critical Care
Committee.
Recommendation 12. We recommended that the facility collect and report to VHA the
percent of eligible patients given tissue plasminogen activator, the percent of patients
with stroke symptoms who had the stroke scale completed, and the percent of patients
screened for difficulty swallowing before oral intake.
Concur
Facility response: A QM Specialist has been identified to collect and report Acute
Ischemic Stroke quality indicators. Training on the quality indicator data collection and
data analysis will occur by September 30, 2014. Quality indicator data will be presented
quarterly to the Critical Care Committee (CCC). Discussion and recommended
improvement actions will be documented in the CCC minutes.

that the Restorative Care Coordinator documents patient restorative program goals and
progress weekly in accordance with facility policy and that compliance be monitored.
Concur
Target date for completion: J anuary 31, 2015
Facility response: The unit specific memorandum (USM) 003T-24, Community Living
Center Restorative Nursing Program, will be revised to reflect a monthly assessment of
the restorative goals that is documented in CPRS. The USM changes will be completed
by September 30, 2014. The Restorative Care Nurse will be placed on the work
schedule for administrative time for a minimum of 48 hours a month to complete
documentation and any other administrative duties for the Restorative Care program.
Monthly compliance monitoring will be done by the Associate Chief Nurse and reported
to the CLC Steering Committee.
that initial patient safety screenings are conducted and documented in patients
electronic health records and that compliance be monitored.
Concur
Facility response: MRI primary and secondary patient safety screens are on the same
piece of paper. Primary screen will be completed by the radiology scheduler at the time
MRI is scheduled. Education has been completed with staff regarding the necessity for
legible full signature (first and last name) and date. Signature requirements include
both staff members and patient/caregiver. Provider order sets for MRI ordering will be
changed to include primary safety screening questions. Radiology Supervisor will do a
100% review of safety screens beginning J uly 1, 2014, and continuing through the end
of September 2014. Following the end of the 90 day 100% review, the Radiology
Supervisor will do random audits and report results to the MRI Safety Committee on a
quarterly basis.
that secondary patient safety screenings are completed immediately prior to magnetic
resonance imaging and placed in patients electronic health records, that
any contraindications are identified and resolution documented prior to the scan,
that Level 2 personnel conducting the secondary screenings sign the forms prior to the
scan, and that compliance be monitored.
Concur

Facility response: Secondary screen will be completed by the MRI Tech on the same
day of the scan immediately prior to beginning the scan. Education has been
completed with staff regarding the necessity for legible full signature (first and last
name) and date. Signature requirements include both staff members and
patient/caregiver. Radiologist, Radiology Supervisor and Clinic Application Coordinator
will develop CPRS changes to assist with the identification and resolution of
contraindications identified on the safety screen. These changes will be put into place
by August 31, 2014, and include: MRI contraindications note title in CPRS, to be used
by the Radiologist and/or Level 2 MRI personnel for documenting contraindications and
resolution. Radiology Supervisor will run a quarterly list of contraindication note titles
and audit those charts for resolution and appropriate documentation. Results will be
reported to the MRI Safety Committee on a quarterly basis.
Recommendation 16. We recommended that the facility implement processes to
monitor compliance with colorectal cancer timeliness and patient notification
requirements.
Concur
Facility response: The Endoscopy Nurse role has been modified to a Case
Management model. The Endoscopy Nurse is responsible for monitoring all aspects of
the colorectal cancer screening process for all FOBT+Veterans and communicating
with providers as indicated. Tracking of all FOBT+ Veterans started in J uly 2014.
Primary Care and Surgery providers will be educated on documentation of patient
notification of test results and follow up plan by September 30, 2014. Compliance
monitoring will be done by the Endoscopy Nurse and reported quarterly to the
Invasive/Operative Committee.

Appendix E
OIG Contact and Staff Acknowledgments
Contact For more information about this report, please contact the OIG
at (202) 461-4720.
Onsite Trina Rollins, MS, PA-C, Team Leader
Contributors Gayle Karamanos, MS, PA-C
Cathleen King, MHA, CRRN
Annette Nowak, Office of Investigations
Other
Contributors
Elizabeth Bullock
Shirley Carlile, BA
Paula Chapman, CTRS
Lin Clegg, PhD
Marnette Dhooghe, MS
J eff J oppie, BS
Misti Kincaid, BS
Nathan McClafferty, MS
Larry Ross, MS
Patrick Smith, M. Stat
J ulie Watrous, RN, MS
J arvis Yu, MS

Appendix F
Report Distribution
VA Distribution
Office of the Secretary
VHA
Assistant Secretaries
General Counsel
Director, Rocky Mountain Network (10N19)
Director, Grand J unction VA Medical Center (575/00)
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: Michael F. Bennet, Orrin G. Hatch, Mike Lee, Mark Udall
U.S. House of Representatives: J ason Chaffetz, Scott Tipton
This report is available at www.va.gov/oig.

Appendix G
Endnotes
a
References used for this topic included:
VHA Directive 2009-043, Quality Management System, September 11, 2009.
VHA Handbook 1050.01, VHA National Patient Safety Improvement Handbook, March 4, 2011.
VHA Directive 2010-017, Prevention of Retained Surgical Items, April 12, 2010.
VHA Directive 2010-025, Peer Review for Quality Management, J une 3, 2010.
VHA Directive 2010-011, Standards for Emergency Departments, Urgent Care Clinics, and Facility Observation
Beds, March 4, 2010.
VHA Directive 2009-064, Recording Observation Patients, November 30, 2009.
VHA Handbook 1100.19, Credentialing and Privileging, October 15, 2012.
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, September 19, 2012.
VHA Directive 6300, Records Management, J uly 10, 2012.
VHA Directive 2009-005, Transfusion Utilization Committee and Program, February 9, 2009.
VHA Handbook 1106.01, Pathology and Laboratory Medicine Service Procedures, October 6, 2008.
b
VHA Directive 2011-007, Required Hand Hygiene Practices, February 16, 2011.
VHA Handbook 1121.01, VHA Eye Care, March 10, 2011.
VA National Center for Patient Safety, Multi-Dose Pen Injectors, Patient Safety Alert 13-04, J anuary 17, 2013.
Adenovirus-Associated Epidemic Keratoconjunctivitis Outbreaks Four States, 20082010, Centers for Disease
Control and Prevention Morbidity and Mortality Weekly Report, August 16, 2013.
Various requirements of The J oint Commission, the Occupational Safety and Health Administration, the
American National Standards Institute/Advancing Safety in Medical Technology, the Centers for Disease Control
and Prevention, the International Association of Healthcare Central Service Materiel Management ,the National
Fire Protection Association, the Health Insurance Portability and Accountability Act, Underwriters Laboratories.
c
VHA Handbook 1108.06, Inpatient Pharmacy Services, June 27, 2006.
VHA Handbook 1108.05, Outpatient Pharmacy Services, May 30, 2006.
VHA Directive 2011-012, Medication Reconciliation, March 9, 2011.
Manufacturers instructions for Ciproand Levaquin.
Various requirements of The J oint Commission.
d
VHA Handbook 1120.04, Veterans Health Education and Information Core Program Requirements,
J uly 29, 2009.
The J oint Commission, Comprehensive Accreditation Manual for Hospitals, J uly 2013.
e
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),
J anuary 31, 2013.
f
VHA Handbook 1142.01, Criteria and Standards for VA Community Living Centers (CLC), August 13, 2008.
VHA Handbook 1142.03, Requirements for Use of the Resident Assessment Instrument (RAI) Minimum Data Set
(MDS), J anuary 4, 2013.
Centers for Medicare and Medicaid Services, Long-Term Care Facility Resident Assessment Instrument Users
Manual, Version 3.0, May 2013.
VHA Manual M-2, Part VIII, Chapter 1, Physical Medicine and Rehabilitation Service, October 7, 1992.
Various requirements of The J oint Commission.

g
VHA Handbook 1105.05, Magnetic Resonance Imaging Safety, J uly 19, 2012.
Emanuel Kanal, MD, et al., ACR Guidance Document on MR Safe Practices: 2013, Journal of Magnetic
Resonance Imaging, Vol. 37, No. 3, J anuary 23, 2013, pp. 501530.
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.
h
The references used for this topic were:
VHA Directive 2007-004, Colorectal Cancer Screening, J anuary 12, 2007 (corrected copy).
VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009.

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