VA OIG Report On Cincinnati VA

Office of Healthcare Inspections
VETERANS HEALTH ADMINISTRATION
Comprehensive Healthcare
Inspection of the Cincinnati
VA Medical Center in Ohio
CHIP REPORT REPORT #20-01276-131 MAY 19, 2021

The mission of the Office of Inspector General is to
serve veterans and the public by conducting effective
oversight of the programs and operations of the
Department of Veterans Affairs through independent
audits, inspections, reviews, and investigations.
In addition to general privacy laws that govern release of medical

information, disclosure of certain veteran health or other private
information may be prohibited by various federal statutes including, but
not limited to, 38 U.S.C. §§ 5701, 5705, and 7332, absent an exemption or
other specified circumstances. As mandated by law, the OIG adheres to
privacy and confidentiality laws and regulations protecting veteran health
or other private information in this report.
Report suspected wrongdoing in VA programs and operations

to the VA OIG Hotline:
www.va.gov/oig/hotline
1-800-488-8244
Figure 1. Cincinnati VA Medical Center in Ohio.
Source: https://vaww.va.gov/directory/guide/ (accessed July 27, 2020).
VA OIG 20-01276-131 | Page i | May 19, 2021

Inspection of the Cincinnati VA Medical Center in Ohio
Abbreviations
ADPCS Associate Director for Patient Care Services
CBOC community-based outpatient clinic
CHIP Comprehensive Healthcare Inspection Program
CLC community living center
COVID-19 coronavirus disease
FPPE focused professional practice evaluation
FY fiscal year
HRS high risk for suicide
LIP licensed independent practitioner
LST life-sustaining treatment
LSTD life-sustaining treatment decision
OIG Office of Inspector General
OPPE ongoing professional practice evaluation
QSV quality, safety, and value
RME reusable medical equipment
SAIL Strategic Analytics for Improvement and Learning
SOP standard operating procedure
SPC suicide prevention coordinator
SPS Sterile Processing Services
TJC The Joint Commission
UM utilization management
VHA Veterans Health Administration
VISN Veterans Integrated Service Network
WH-PCP women’s health primary care provider
VA OIG 20-01276-131 | Page ii | May 19, 2021

Report Overview
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP)
report provides a focused evaluation of the quality of care delivered in the inpatient and
outpatient settings of the Cincinnati VA Medical Center, which includes two divisions in
Cincinnati and Fort Thomas, and multiple outpatient clinics in Kentucky, Indiana, and Ohio. The
inspection covers key clinical and administrative processes that are associated with promoting
quality care.
Comprehensive healthcare inspections are one element of the OIG’s overall efforts to ensure that
the nation’s veterans receive high-quality and timely VA healthcare services. The inspections are
performed approximately every three years for each facility. The OIG selects and evaluates
specific areas of focus each year.
The OIG team looks at leadership and organizational risks, and at the time of the inspection,
focused on the following additional areas:
1. COVID-19 pandemic readiness and response1
2. Quality, safety, and value
3. Medical staff privileging
4. Medication management (targeting long-term opioid therapy for pain)
5. Mental health (focusing on the suicide prevention program)
6. Care coordination (spotlighting life-sustaining treatment decisions)
7. Women’s health (examining comprehensive care)
8. High-risk processes (emphasizing reusable medical equipment)
This unannounced virtual review was conducted during the week of July 27, 2020, at the
Cincinnati VA Medical Center. The OIG held interviews and reviewed clinical and
administrative processes related to specific areas of focus that affect patient outcomes. Although
the OIG reviewed a broad spectrum of processes, the sheer complexity of VA medical facilities
limits inspectors’ ability to assess all areas of clinical risk. The findings presented in this report
are a snapshot of this medical center’s performance within the identified focus areas at the time
of the OIG review. Although it is difficult to quantify the risk of patient harm, the findings in this
report may help this medical center and other Veterans Health Administration (VHA) facilities
1
“Naming the Coronavirus Disease (COVID-19) and the Virus that Causes It,” World Health Organization,
accessed August 25, 2020, https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-
guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it. COVID-19 (coronavirus
disease) is an infectious disease caused by the “severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).”
VA OIG 20-01276-131 | Page iii | May 19, 2021

identify vulnerable areas or conditions that, if properly addressed, could improve patient safety
and healthcare quality.
Inspection Results
The OIG noted opportunities for improvement in several areas reviewed and issued 16
recommendations to the Medical Center Director, Chief of Staff, and Associate Director for
Patient Care Services. These opportunities for improvement are briefly described below.
Leadership and Organizational Risks

At the time of the OIG’s virtual review, the medical center’s leadership team consisted of the
Medical Center Director, Chief of Staff, Associate Director for Patient Care Services, and
Associate Director. The medical center did not have a designated executive-level committee or
board with the authority and responsibility to establish policy, maintain quality care standards, or
perform organizational management and strategic planning. Organizational communications and
accountability were managed through a committee reporting structure, with the Director
overseeing the Administrative Executive Board, Clinical Executive Board, and Nurse Executive
Committee. The Director also chaired the Management Briefings, in which various clinical
services report on a rotating basis. The leaders monitored patient safety and care through the
Quality, Safety and Value Committee which was responsible for tracking and trending quality of
care and patient outcomes.2
During the OIG review, three of the four executive leadership positions were occupied by acting
staff. The medical center director position became vacant on February 16, 2020, and the
permanent Associate Director for Patient Care Services began serving as acting Director at that
time. The resulting vacant Associate Director for Patient Care Services role has since been filled
temporarily by four separate medical center staff. In addition, six different employees had served
as the acting Chief of Staff since the position became vacant in May 2019. The Associate
Director was permanently assigned in October 2019.
The OIG found that medical center averages for the All Employee Survey leadership questions
were similar to or worse than the VHA averages. Opportunities appeared to exist for the acting
Chief of Staff to improve employee attitudes toward the workplace. Patients generally appeared
satisfied with the care provided; however, gender-specific results highlighted opportunities to
improve experiences in the inpatient and patient-centered medical home settings.
2
At the time of the OIG review, the committee was called the Quality, Safety and Value Committee. The medical
center subsequently changed the name to the Quality and Patient Safety Council which is reflected in the action
plans and updated in figure 4.
VA OIG 20-01276-131 | Page iv | May 19, 2021

The inspection team also reviewed accreditation agency findings, sentinel events, and disclosures
of adverse patient events and identified organizational risk factors.3 Specifically, the OIG noted
concerns with processes related to identification of sentinel events and institutional disclosure.
The VA Office of Operational Analytics and Reporting adopted the Strategic Analytics for
Improvement and Learning Value Model to help define performance expectations within VA
with “measures on healthcare quality, employee satisfaction, access to care, and efficiency.”
Despite noted limitations for identifying all areas of clinical risk, the data are presented as one
way to understand the similarities and differences between the top and bottom performers within
VHA.4
The executive leaders were knowledgeable within their scope of responsibilities about VHA data
and/or system-level factors contributing to specific poorly performing Strategic Analytics for
Improvement and Learning and community living center measures.5 In individual interviews, the
executive leadership team members were generally able to speak in depth about actions taken
during the previous 12 months to maintain or improve organizational performance, employee
satisfaction, and/or patient experiences.
COVID-19 Pandemic Readiness and Response

The results of the OIG’s evaluation of the medical center’s COVID-19 pandemic readiness and
response were compiled and reported with other facilities in a separate publication to provide
stakeholders with a more comprehensive picture of regional VHA challenges and ongoing
efforts.6
Quality, Safety, and Value

The medical center complied with requirements for the establishment of a committee responsible
for quality, safety, and value oversight functions; completion of utilization management reviews;
and submission of the annual patient safety report. However, the OIG identified weaknesses in
the Quality, Safety, and Value Committee’s implementation of improvement actions, protected
peer reviews, and root cause analysis processes.
3
VHA Directive 1190, Peer Review for Quality Management, November 21, 2018. A sentinel event is an incident or
condition that results in patient “death, permanent harm, or severe temporary harm and intervention required to
sustain life.”
4
“Strategic Analytics for Improvement and Learning (SAIL) Value Model,” VHA Support Service Center, accessed
March 6, 2020, https://vssc.med.va.gov. (This is an internal VA website not publicly accessible.)
5
VHA Directive 1149, Criteria for Authorized Absence, Passes, and Campus Privileges for Residents in VA
Community Living Centers, June 1, 2017. Community living centers, previously known as nursing home care units,
provide a skilled nursing environment and a variety of interdisciplinary programs for persons needing short- and
long-stay services.
6
VA OIG, Comprehensive Healthcare Inspection of Facilities’ COVID-19 Pandemic Readiness and Response in
Veterans Integrated Service Networks 10 and 20, Report No. 21-01116-98, March 16, 2021.
VA OIG 20-01276-131 | Page v | May 19, 2021

Medical Staff Privileging

The OIG identified deficiencies with focused and ongoing professional practice evaluation and
healthcare provider exit review processes.7
Medication Management
The OIG team observed compliance with many elements of expected performance, including
pain screening, aberrant behavior risk assessment, urine drug testing, and multidisciplinary pain
management committee processes. However, the OIG found a deficiency with informed consent.
Mental Health
The OIG found compliance with the requirements for suicide prevention coordinator
designation, suicide prevention training, and monthly outreach activities. However, the OIG
identified a deficiency with timely suicide safety plan completion.
Women’s Health
The medical center complied with many of the requirements for women’s health. The OIG noted
concerns with community-based outpatient clinic-designated women’s health primary care
providers and the Women Veterans Advisory Committee.8
High-Risk Processes
The medical center met requirements for quality assurance monitoring. However, the OIG
identified deficiencies with standard operating procedures, the instrument tracking system,
eyewash station testing, and staff training.
Conclusion
The OIG conducted a detailed inspection across nine key areas (two administrative and seven
clinical) and subsequently issued 16 recommendations for improvement to the Medical Center
Director, Chief of Staff, and Associate Director for Patient Care Services. The number of
recommendations should not be used, however, as a gauge for the overall quality of care
7
Office of Safety and Risk Awareness, Office of Quality and Performance, Provider Competency and Clinical Care
Concerns Including: Focused Clinical Care Review and FPPE for Cause Guidance, July 2016 (Revision 2). An
ongoing professional practice evaluation is “the ongoing monitoring of privileged providers to confirm the quality of
care delivered and ensures patient safety.” A focused professional practice evaluation is “a time-limited process
whereby the clinical leadership evaluates the privilege-specific competence of a provider who does not yet have
documented evidence of competently performing the requested privilege(s) at the facility.”
8
At the time of the OIG review, the committee was called the Women Veterans Advisory Committee. The medical
center subsequently changed the name to the Women Veterans Health Committee which is reflected in the action
VA OIG 20-01276-131 | Page vi | May 19, 2021

provided at this medical center. The intent is for medical center leaders to use these
recommendations as a road map to help improve operations and clinical care. The
recommendations address systems issues as well as other less-critical findings that, if not
addressed, may eventually interfere with the delivery of quality health care.
Comments
The Veterans Integrated Service Network Director and Medical Center Director agreed with the
comprehensive healthcare inspection findings and recommendations and provided acceptable
improvement plans. (See appendixes G and H, pages 70–71, and the responses within the body
of the report for the full text of the directors’ comments.) The OIG considers recommendations
1, 2, 3, and 11 closed. The OIG will follow up on the planned actions for the open
recommendations until they are completed.
JOHN D. DAIGH, JR., M.D.

Assistant Inspector General
for Healthcare Inspections
VA OIG 20-01276-131 | Page vii | May 19, 2021

Contents
Abbreviations .................................................................................................................................. ii
Report Overview ............................................................................................................................ iii
Inspection Results ..................................................................................................................... iv
Purpose and Scope ...........................................................................................................................1
Methodology ....................................................................................................................................3
Results and Recommendations ........................................................................................................5
Leadership and Organizational Risks..........................................................................................5
COVID-19 Pandemic Readiness and Response ........................................................................22
Quality, Safety, and Value ........................................................................................................23
Recommendation 1 ...................................................................................................................26
Recommendation 2 ...................................................................................................................27
Recommendation 3 ...................................................................................................................28
Medical Staff Privileging ..........................................................................................................29
Recommendation 4 ...................................................................................................................31
Recommendation 5 ...................................................................................................................32
Recommendation 6 ...................................................................................................................33
Recommendation 7 ...................................................................................................................33
Recommendation 8 ...................................................................................................................34
VA OIG 20-01276-131 | Page viii | May 19, 2021

Recommendation 9 ...................................................................................................................35
Medication Management: Long-Term Opioid Therapy for Pain ..............................................37
Mental Health: Suicide Prevention Program.............................................................................40
Recommendation 10 .................................................................................................................44
Care Coordination: Life-Sustaining Treatment Decisions ........................................................45
Women’s Health: Comprehensive Care ....................................................................................48
Recommendation 11 .................................................................................................................50
Recommendation 12 .................................................................................................................51
High-Risk Processes: Reusable Medical Equipment ................................................................52
Recommendation 13 .................................................................................................................54
Recommendation 14 .................................................................................................................54
Recommendation 15 .................................................................................................................55
Recommendation 16 .................................................................................................................56
Appendix A: Comprehensive Healthcare Inspection Program Recommendations .......................57
Appendix B: Medical Center Profile .............................................................................................60
Appendix C: VA Outpatient Clinic Profiles ..................................................................................62
Appendix D: Patient Aligned Care Team Compass Metrics .........................................................64
Appendix E: Strategic Analytics for Improvement and Learning (SAIL) Metric Definitions
........................................................................................................................................................66
VA OIG 20-01276-131 | Page ix | May 19, 2021

Appendix F: Community Living Center (CLC) Strategic Analytics for Improvement and
Learning (SAIL) Measure Definitions .... ....................................................................................68
Appendix G: VISN Director Comments ........................................................................................70
Appendix H: Interim Medical Center Director Comments............................................................71
OIG Contact and Staff Acknowledgments ....................................................................................72
Report Distribution ........................................................................................................................73
VA OIG 20-01276-131 | Page x | May 19, 2021

Purpose and Scope

The purpose of the Office of Inspector General (OIG) Comprehensive Healthcare Inspection
Program (CHIP) is to conduct routine oversight of VA medical facilities providing healthcare
services to veterans. This report’s evaluation of the quality of care delivered in the inpatient and
outpatient settings of the Cincinnati VA Medical Center examines a broad range of key clinical
and administrative processes associated with positive patient outcomes. The OIG reports its
findings to Veterans Integrated Service Network (VISN) and medical center leaders so that
informed decisions can be made to improve care.1
Effective leaders manage organizational risks by establishing goals, strategies, and priorities to
improve care; setting expectations for quality care delivery; and promoting a culture to sustain
positive change.2 Effective leadership has been cited as “among the most critical components
that lead an organization to effective and successful outcomes.”3 Figure 2 illustrates the direct
relationships between leadership and organizational risks and the processes used to deliver health
care to veterans.
Because of the COVID-19 pandemic, the OIG converted this site visit to a virtual review, paused
physical inspection steps—especially those involved in the environment of care-focused review
topic—and initiated a COVID-19 pandemic readiness and response evaluation.
As such, to examine risks to patients and the organization, the OIG focused on core processes in
the following nine areas of administrative and clinical operations (see figure 2):4
1. Leadership and organizational risks
2. COVID-19 pandemic readiness and response5
3. Quality, safety, and value (QSV)
4. Medical staff privileging
1
VA administers healthcare services through a network of 18 regional offices nationwide referred to as the Veterans
Integrated Service Network.
2
Anam Parand et al., “The role of hospital managers in quality and patient safety: a systematic review,” British
Medical Journal 4, no. 9 (September 5, 2014): e005055.
3
Danae Sfantou et al., “Importance of Leadership Style Towards Quality of Care Measures in Healthcare Settings:
A Systematic Review,” Healthcare (Basel) 5, no. 4, (December 2017): 73.
4
Virtual CHIP site visits address these processes during fiscal year 2020 quarter 4 (July 1, 2020, through
September 30, 2020); they may differ from prior years’ focus areas.
5
“Naming the Coronavirus Disease (COVID-19) and the Virus that Causes It,” World Health Organization,
accessed August 25, 2020, https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-
guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it. COVID-19 (coronavirus
disease) is an infectious disease caused by the “severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).”
VA OIG 20-01276-131 | Page 1 | May 19, 2021

5. Medication management (targeting long-term opioid therapy for pain)

6. Mental health (focusing on the suicide prevention program)
7. Care coordination (spotlighting life-sustaining treatment decisions)
8. Women’s health (examining comprehensive care)
9. High-risk processes (emphasizing reusable medical equipment)
Figure 2. Fiscal year (FY) 2020 comprehensive healthcare inspection of operations and services.
Source: VA OIG.
VA OIG 20-01276-131 | Page 2 | May 19, 2021

Methodology
The Cincinnati VA Medical Center is a two-division campus with locations in Cincinnati, Ohio,
and Fort Thomas, Kentucky, and outpatient clinics in Kentucky, Indiana, and Ohio. Additional
details about the types of care provided by the medical center can be found in appendixes B and
C.
To determine compliance with the Veterans Health Administration (VHA) requirements related
to patient care quality, clinical functions, and the environment of care, the inspection team
reviewed OIG-selected clinical records, administrative and performance measure data, and
accreditation survey reports.6
The OIG inspection team interviewed executive leaders and discussed processes, validated
findings, and explored reasons for noncompliance with staff.
The inspection examined operations from October 21, 2017, through July 31, 2020, the last day
of the unannounced multiday evaluation.7 During the virtual site visit, the OIG referred concerns
beyond the scope of the review to the OIG’s hotline management team for further review.
The results of the OIG’s evaluation of the medical center’s COVID-19 pandemic readiness and
response were compiled and reported with other facilities in a separate publication to provide
stakeholders with a more comprehensive picture of regional VHA challenges and ongoing
efforts.8
Oversight authority to review the programs and operations of VA medical facilities is authorized
by the Inspector General Act of 1978.9 The OIG reviews available evidence within a specified
scope and methodology and makes recommendations to VA leaders, if warranted. Findings and
recommendations do not define a standard of care or establish legal liability.
This report’s recommendations for improvement address problems that can influence the quality
of patient care significantly enough to warrant OIG follow-up until the medical center completes
corrective actions. The Medical Center Director’s responses to the report recommendations
appear within each topic area. The OIG accepted the action plans that the medical center leaders
developed based on the reasons for noncompliance.
6
The OIG did not review VHA’s internal survey results and instead focused on OIG inspections and external
surveys that affect facility accreditation status.
7
The range represents the time period from the prior CHIP site visit to the completion of the unannounced, multiday
virtual CHIP visit in July 2020.
8
9
Pub. L. No. 95-452, 92 Stat 1105, as amended (codified at 5 U.S.C. App. 3).
VA OIG 20-01276-131 | Page 3 | May 19, 2021

The OIG conducted the inspection in accordance with OIG procedures and Quality Standards for
Inspection and Evaluation published by the Council of the Inspectors General on Integrity and
Efficiency.
VA OIG 20-01276-131 | Page 4 | May 19, 2021

Results and Recommendations

Leadership and Organizational Risks
Stable and effective leadership is critical to improving care and sustaining meaningful change
within a VA healthcare system. Leadership and organizational risks can affect the healthcare
system’s ability to provide care in the clinical focus areas.10 To assess the medical center’s risks,
the OIG considered several indicators:
1. Executive leadership position stability and engagement
2. Employee satisfaction
3. Patient experience
4. Accreditation surveys and oversight inspections
5. Identified factors related to possible lapses in care and medical center response
6. VHA performance data (medical center)
7. VHA performance data (CLC)11
Executive Leadership Position Stability and Engagement

Because each VA facility organizes its leadership structure to address the needs and expectations
of the local veteran population it serves, organizational charts may differ across facilities.
Figure 3 illustrates this medical center’s reported organizational structure. The medical center
has a leadership team consisting of the Director, Chief of Staff, Associate Director for Patient
Care Services (ADPCS), and Associate Director. The Chief of Staff and ADPCS oversee patient
care which requires managing service directors and chiefs of programs and practices.
10
Laura Botwinick, Maureen Bisognano, and Carol Haraden, Leadership Guide to Patient Safety, Institute for
Healthcare Improvement, Innovation Series White Paper, 2006.
11
VHA Directive 1149, Criteria for Authorized Absence, Passes, and Campus Privileges for Residents in VA
Community Living Centers, June 1, 2017. CLCs, previously known as nursing home care units, provide a skilled
nursing environment and a variety of interdisciplinary programs for persons needing short- and long-stay services.
VA OIG 20-01276-131 | Page 5 | May 19, 2021

Medical Center Director
Chief of Staff ADPCS Associate Director
Chaplain Community Living Center Engineering Quality & Clinical Informatics

Dental Nursing Environmental Management
Education Sterile Processing Service Service
Eye Center Fiscal
Medical Human Resource
Management Service
Mental Health
Industrial Health & Safety
Neurology
Information Resource
Pathology & Laboratory Management
Primary Care Logistics
Radiology Nutrition & Food Service
Rehabilitation Patient Business Service
Research Pharmacy
Social Work Police
Surgery Prosthetics
Voluntary
Figure 3. Medical center organizational chart.

Source: Cincinnati VA Medical Center (received July 27, 2020).
During the OIG virtual site visit, three of the four executive leadership positions were occupied
by acting staff. The medical center director position became vacant on February 16, 2020, and
the permanent ADPCS began serving as acting Director at that time. The resulting vacant
ADPCS role has since been filled temporarily by four separate medical center staff. In addition,
six different employees had served as the acting Chief of Staff since the position became vacant
in May 2019. The Associate Director was permanently assigned in October 2019 (see table 1).
Table 1. Executive Leader Assignments

Leadership Position Assignment Date
Medical Center Director February 16, 2020 (acting)
Chief of Staff May 17, 2019 (acting)
Associate Director for Patient Care Services January 20, 2019 (permanent)
February 16, 2020 (acting)
Associate Director October 10, 2019
Source: Cincinnati VA Medical Center Supervisory Human Resources Officer
(received July 30, 2020).
To help assess the medical center executive leaders’ engagement, the OIG interviewed the acting
Director, acting Chief of Staff, acting ADPCS, and Associate Director regarding their knowledge
of various performance metrics and their involvement and support of actions to improve or
sustain performance.
VA OIG 20-01276-131 | Page 6 | May 19, 2021

The executive leaders were knowledgeable within their scope of responsibilities about VHA data
and/or system-level factors contributing to specific poorly performing Strategic Analytics for
Improvement and Learning (SAIL) and Community Living Center (CLC) SAIL measures. In
individual interviews, the executive leadership team were able to speak knowledgeably about
actions taken during the previous 12 months to maintain or improve organizational performance,
employee satisfaction, and/or patient experiences. These are discussed in greater detail below.
The medical center did not have a designated executive-level committee or board to establish
policy, maintain quality care standards, or perform organizational management and strategic
planning. The Medical Center Director oversees the Administrative Executive Board, Clinical
Executive Board, and Nurse Executive Committee. The Director also chairs the Management
Briefings, in which various clinical services report out on a rotating basis.
The medical center leaders monitored patient safety and care through the Quality, Safety and
Value Committee. The Quality, Safety and Value Committee was responsible for tracking and
trending quality of care and patient outcomes (see figure 4).12
12
At the time of the OIG review, the committee was called the Quality, Safety and Value Committee. The medical
center subsequently changed the name to the Quality and Patient Safety Council which is updated in figure 4.
VA OIG 20-01276-131 | Page 7 | May 19, 2021

Medical Center Director
Administrative Clinical Executive Nurse Executive Management

Executive Board Board Committee Briefings
Capital Planning Committee Patient Care Services Quality and Patient Safety
Ancillary Diagnostic Testing Council
Clinical Product Review Committee
Committee
Affiliation Diagnostic Testing
Environment of Care Committee
Committee
Cancer Care Committee &
Equipment Committee Tumor Board
Space Committee Clinical Informatics and
VA Voluntary Services Staff Information Technology
Advisory Committee Innovation Committee/BCMA
Veterans Transportation Continuity of Care and CNH
Service Committee Oversight Committee
Credentialing and Privileging
Professional Standards
Board
Critical Care Committee
Disruptive Behavior
Committee
Environmental and Hospital
Infection Control Committee
Gradute Medical Education
Commmittee
Health Records Integrity
Committee
Home Oxygen Committee
Nutrition Committee &
Dysphagia Committee
Operative and Invasive
Procedures Committee
Pain Council Committee
Pharmacy & Therapeutics
Committee
Radiation Safety Council
Research and Development
Committee
Resuscitation Outcomes
RME Committee
Telehealth
Tissue and Transfusion
Review Committee
VA Community Care
Oversight Committee
Whole Health Steering
Committee
Women Veterans Health
Committee
Figure 4. VA medical center committee reporting structure.

Source: Cincinnati VA Medical Center (received August 31, 2020, and April 13, 2021).
BCMA = Bar Code Medication Administration
CNH = Community Nursing Home
RME = Reusable Medical Equipment
Employee Satisfaction
The All Employee Survey “is an annual, voluntary, census survey of VA workforce experiences.
The data are anonymous and confidential.” Since 2001, the instrument has been refined several
VA OIG 20-01276-131 | Page 8 | May 19, 2021

times in response to VA leaders’ inquiries on VA culture and organizational health.13 Although

the OIG recognizes that employee satisfaction survey data are subjective, they can be a starting
point for discussions, indicate areas for further inquiry, and be considered along with other
information on medical center leadership.
To assess employee attitudes toward medical center leaders, the OIG reviewed employee
satisfaction survey results from VHA’s All Employee Survey from October 1, 2018, through
September 30, 2019.14 Table 2 provides relevant survey results for VHA, the medical center, and
selected executive leaders. It summarizes employee attitudes toward the leaders as expressed in
VHA’s All Employee Survey. The OIG found the medical center’s averages for the selected
survey questions were similar to or lower than the VHA averages.15 However, executive leaders’
scores were generally higher than those for VHA and the medical center. Although the survey
results are not indicative of most current leaders’ performance, they may still provide relevant
insights into employee satisfaction improvement opportunities.16
Table 2. Survey Results on Employee Attitudes toward Medical Center

Leaders (October 1, 2018, through September 30, 2019)
Questions/Survey Scoring VHA Medical Director Chief of ADPCS Assoc.
Items Average Center Average Staff Average Director
Average Average Average
All Employee 0–100 where 72.6 68.8 – 69.0 95.0 96.9

Survey: higher
Servant Leader scores are
Index Composite.* more
favorable
13
“Survey Instruments,” VA Workforce Surveys Portal, VHA Support Service Center, accessed May 3, 2021,
http://aes.vssc.med.va.gov/SurveyInstruments/Pages/default.aspx. (This is an internal website not publicly
accessible.)
14
Ratings are based on responses by employees who report to or are aligned under the Chief of Staff, ADPCS, and
Associate Director. Scores were not available for the Medical Center Director.
15
The OIG makes no comment on the adequacy of the VHA average for each selected survey element. The VHA
average is used for comparison purposes only.
16
It is important to note that the 2019 All Employee Survey results are not reflective of the staff currently serving as
acting Chief of Staff, acting ADPCS, and Associate Director, as they were not in their positions at the time of the
survey. The ADPCS scores are reflective of the full-time ADPCS, who has served as acting Director since February
16, 2020.
VA OIG 20-01276-131 | Page 9 | May 19, 2021


All Employee 1 (Strongly 3.4 3.3 – 3.3 4.7 4.7

Survey: Disagree) –5
In my (Strongly
organization, Agree)
senior leaders
generate high
levels of
motivation and
commitment in the
workforce.
My organization’s (Strongly
senior leaders Agree)
maintain high
standards of
honesty and
integrity.
I have a high level (Strongly
of respect for my Agree)
organization's
senior leaders.
Source: VA All Employee Survey (accessed June 23, 2020, and August 20, 2020).
*The Servant Leader Index “is a summary measure of the work environment being a place where organizational
goals are achieved by empowering others. This includes focusing on collective goals, encouraging contribution from
others, and then positively reinforcing others’ contributions. Servant Leadership occurs at all levels of the
organization, where individuals (supervisors, staff) put others’ needs before their own.”
Table 3 summarizes employee attitudes toward the workplace as expressed in VHA’s All
Employee Survey.17 Medical center averages for the selected survey questions were similar to or
worse than VHA averages. The Associate Director and ADPCS averages were generally better
than VHA and the medical center. However, the acting Chief of Staff appears to have
opportunities to improve employee attitudes toward the workplace.
17
Ratings are based on responses by employees who report to or are aligned under the Chief of Staff, ADPCS, and
Associate Director. Scores were not available for the Medical Center Director.
VA OIG 20-01276-131 | Page 10 | May 19, 2021

Table 3. Survey Results on Employee Attitudes toward the Workplace

(October 1, 2018, through September 30, 2019)
I can disclose a (Strongly
suspected violation Agree)
of any law, rule, or
regulation without
fear of reprisal.
Employees in my (Strongly
workgroup do what Agree)
is right even if they
feel it puts them at
risk (e.g., risk to
reputation or
promotion, shift
reassignment, peer
relationships, poor
performance
review, or risk of
termination).
All Employee 0 (Never) – 1.4 1.6 – 2.5 1.9 0.6
Survey: 6 (Every
In the past year, Day)
how often did you
experience moral
distress at work
(i.e., you were
unsure about the
right thing to do or
could not carry out
what you believed
to be the right
thing)?
Source: VA All Employee Survey (accessed June 23, 2020, and August 20, 2020).
Patient Experience
To assess patient experiences with the medical center, which directly reflect on its leaders, the
OIG team reviewed survey results that relate to the period of October 1, 2018, through
September 30, 2019. VHA’s Patient Experiences Survey Reports provide results from the Survey
of Healthcare Experiences of Patients program. VHA uses industry standard surveys from the
Consumer Assessment of Healthcare Providers and Systems program to evaluate patients’
VA OIG 20-01276-131 | Page 11 | May 19, 2021

experiences with their health care and to support benchmarking its performance against the
private sector.
VHA also collects Survey of Healthcare Experiences of Patients data from Inpatient, Patient-
Centered Medical Home, and Specialty Care surveys. The OIG reviewed responses to four
relevant survey questions that reflect patients’ attitudes toward their healthcare experiences.
Table 4 provides relevant survey results for VHA and the medical center.18 Although two of the
four survey results were slightly lower than the VHA average, patients generally appeared
satisfied with their care experiences.
Table 4. Survey Results on Patient Experience

Questions Scoring VHA Cincinnati
Average Medical
Center
Average
Survey of Healthcare Experiences of The response 68.3 62.9
Patients (inpatient): Would you average is the
recommend this hospital to your percent of
friends and family? “Definitely Yes”
responses.
Patients (inpatient): I felt like a valued average is the
customer. percent of
“Agree” and
“Strongly Agree”
responses.
Patients (outpatient Patient-Centered average is the
Medical Home): I felt like a valued percent of
customer. “Agree” and
responses.
Patients (outpatient specialty care): I average is the
felt like a valued customer. percent of
“Agree” and
responses.
Source: VHA Office of Reporting, Analytics, Performance, Improvement and Deployment
(accessed December 23, 2019).
In 2015, women represented 9.4 percent of the total veteran population in the United States, and
it is projected that women will represent 16.3 percent of living veterans by 2043. Further, from
18
Ratings are based on responses by patients who received care at this medical center.
VA OIG 20-01276-131 | Page 12 | May 19, 2021

2005 to 2015, the number of women veterans using VA health care increased by 46.4 percent,
from almost 240,000 to 455,875.19 For these reasons, it is important for VHA to provide
accessible and inclusive care for women veterans.
The OIG reviewed selected responses to several additional relevant survey questions that reflect
patients’ experiences by gender (see tables 5–7), including those for Inpatient, Patient-Centered
Medical Home, and Specialty Care surveys. The results for male respondents were generally
more favorable than the corresponding VHA national averages, except for those related to
inpatient care. Likewise, female respondent scores were more positive than VHA averages,
except for the patient-centered medical home setting. Medical center leaders appeared to be
actively engaged with male and female patients (for example, conducting veteran town hall
meetings and leadership rounds).
Table 5. Inpatient Survey Results on Experiences by Gender

Questions Scoring VHA* Medical Center
Male Female Male Female
Average Average Average Average
During this hospital stay, how The measure is 84.5 82.8 85.8 88.7
often did doctors treat you calculated as the
with courtesy and respect? percentage of responses
that fall in the top
category (Always).
During this hospital stay, how The measure is 84.8 83.1 83.8 85.5
often did nurses treat you with calculated as the
courtesy and respect? percentage of responses
that fall in the top
category (Always).
Would you recommend this The measure is 68.7 61.8 62.8 64.2
hospital to your friends and calculated as the
family? percentage of responses
in the top category
(Definitely yes).
Source: VHA Office of Reporting, Analytics, Performance, Improvement and Deployment (accessed May 6, 2020).
*The VHA averages are based on 48,259–48,798 male and 2,342–2,359 female respondents, depending on the
question.
The medical center averages are based on 504–509 male and 20–21 female respondents, depending on the
question.
19
VA National Center for Veterans Analysis and Statistics, The Past, Present and Future of Women Veterans,
February 2017.
VA OIG 20-01276-131 | Page 13 | May 19, 2021

Table 6. Patient-Centered Medical Home Survey Results on Patient Experiences

by Gender (October 1, 2018, through September 30, 2019)
In the last 6 months, when The measure is 51.2 43.3 57.1 48.6
you contacted this provider’s calculated as the
office to get an appointment percentage of responses
for care you needed right that fall in the top
away, how often did you get category (Always).
an appointment as soon as
you needed?
you made an appointment for calculated as the
a check-up or routine care percentage of responses
with this provider, how often that fall in the top
did you get an appointment as category (Always).
soon as you needed?
Using any number from 0 to The reporting measure is 71.6 65.7 79.0 52.3
10, where 0 is the worst calculated as the
provider possible and 10 is percentage of responses
the best provider possible, that fall in the top two
what number would you use categories (9, 10).
to rate this provider?
*The VHA averages are based on 79,450–241,828 male and 5,762–13,041 female respondents, depending on
the question.
The medical center averages are based on 650–1,953 male and 27–65 female respondents, depending on the
question.
VA OIG 20-01276-131 | Page 14 | May 19, 2021

Table 7. Specialty Care Survey Results on Patient Experiences by Gender

you contacted this provider’s calculated as the
office to get an appointment percentage of responses
for care you needed right that fall in the top
away, how often did you get category (Always).
an appointment as soon as
you needed?
you made an appointment for calculated as the
a check-up or routine care percentage of responses
with this provider, how often that fall in the top
did you get an appointment category (Always).
as soon as you needed?
Using any number from 0 to The reporting measure is 70.4 70.1 71.0 89.5
10, where 0 is the worst calculated as the
provider possible and 10 is percentage of responses
the best provider possible, that fall in the top two
what number would you use categories (9, 10).
to rate this provider?
*The VHA averages are based on 65,968–208,722 male and 3,460–11,072 female respondents, depending on
the question.
The medical center averages are based on 539–1,653 male and 17– 65 female respondents, depending on the
question.
Accreditation Surveys and Oversight Inspections

To further assess leadership and organizational risks, the OIG reviewed recommendations from
previous inspections and surveys—including those conducted for cause—by oversight and
accrediting agencies to gauge how well leaders respond to identified problems.20 Table 8
summarizes the relevant medical center inspections most recently performed by the OIG and The
20
“Profile Definitions and Methodology: Joint Commission Accreditation,” American Hospital Directory, accessed
December 12, 2020, https://www.ahd.com/definitions/prof_accred.html. “The Joint Commission conducts for-cause
unannounced surveys in response to serious incidents relating to the health and/or safety of patients or staff or other
reported complaints. The outcomes of these types of activities may affect the accreditation status of an
organization.”
VA OIG 20-01276-131 | Page 15 | May 19, 2021

Joint Commission (TJC).21 Of note, at the time of the OIG virtual review, the medical center had
closed all recommendations for improvement issued since the previous comprehensive
healthcare inspection conducted in October 2017.
At the time of the virtual review, the OIG team also noted the medical center’s current
accreditation by the Commission on Accreditation of Rehabilitation Facilities and the College of
American Pathologists.22 Additional results included the Long Term Care Institute’s inspection
of the medical center’s CLCs.23
Table 8. Office of Inspector General Inspections/The Joint Commission Survey

Accreditation or Inspecting Agency Date of Visit Number of Number of
Recommendations Recommendations
Issued Remaining Open
OIG (Comprehensive Healthcare October 2017 7 0
Inspection Program Review of the
Cincinnati VA Medical Center,
Cincinnati, Ohio, Report No.
17-05398-172, May 23, 2018)
OIG (Follow-up to Clinical and October 2017 0 n/a*
Administrative Concerns at the
Cincinnati VA Medical Center, Ohio,
Report No. 17-05398-177,
May 23, 2018)
TJC Hospital Accreditation July 2019 46 0
TJC Behavioral Health Care 3 0
Accreditation
TJC Home Care Accreditation 11 0
21
VHA Directive 1100.16, Accreditation of Medical Facility and Ambulatory Programs, May 9, 2017. TJC
provides an “internationally accepted external validation that an organization has systems and processes in place to
provide safe and quality-oriented health care.” TJC “has been accrediting VA medical facilities for over 35 years.”
Compliance with TJC standards “facilitates risk reduction and performance improvement.”
22
VHA Directive 1170.01, Accreditation of Veterans Health Administration Rehabilitation Programs, May 9, 2017.
The Commission on Accreditation of Rehabilitation Facilities “provides an international, independent, peer review
system of accreditation that is widely recognized by Federal agencies.” VHA’s commitment is supported through a
system-wide, long-term collaboration with the Commission on Accreditation of Rehabilitation Facilities to achieve
and maintain national accreditation for all appropriate VHA rehabilitation programs. “About the College of
American Pathologists,” College of American Pathologists, accessed April 26, 2021, https://www.cap.org/about-the-
cap. According to the College of American Pathologists, for 75 years it has “fostered excellence in laboratories and
advanced the practice of pathology and laboratory science.” Additionally, as stated in VHA Handbook 1106.01,
Pathology and Laboratory Medicine Service (P&LMS) Procedures, January 29, 2016, VHA laboratories must meet
the requirements of the College of American Pathologists.
23
“About Us,” Long Term Care Institute, accessed on March 6, 2019, http://www.ltciorg.org/about-us/. The Long-
Term Care Institute states that it has been to over 4,000 healthcare facilities conducting quality reviews and over
1,145 external regulatory surveys since 1999. The Long-Term Care Institute is “focused on long term care quality
and performance improvement, compliance program development, and review in long term care, hospice, and other
residential care settings.”
VA OIG 20-01276-131 | Page 16 | May 19, 2021

Accreditation or Inspecting Agency Date of Visit Number of Number of

Recommendations Recommendations
Issued Remaining Open
TJC Opiate Substitution Services June 2018 9 0
(Behavioral Health)
Source: OIG and TJC (inspection/survey results verified with the Chief of Quality Management on July 29, 2020).
*n/a = not applicable
Identified Factors Related to Possible Lapses in Care and Medical

Center Response
Within the healthcare field, the primary organizational risk is the potential for patient harm.
Many factors affect the risk for patient harm within a system, including hazardous environmental
conditions; poor infection control practices; and patient, staff, and public safety. Leaders must be
able to understand and implement plans to minimize patient risk through consistent and reliable
data and reporting mechanisms. The OIG identified weaknesses related to the patient safety
program and completion of timely disclosures.
The OIG requested a list of sentinel events from October 16, 2017, to July 27, 2020; the Patient
Safety Manager and Chief of Quality Management stated that the facility did not identify any
sentinel events during that period.24 However, during the review of root cause analyses listed in
the facility’s fiscal year 2019 Patient Safety Annual Report, the OIG identified four cases that
may have met the criteria for sentinel events. Three of the four cases resulted in the patient’s
death: the first was related to timely treatment for a critical lab value, the second was associated
with a delayed transfer to a community hospital, and the third involved an invasive procedure.
The fourth event concerned an attempted act of self-harm by an unattended patient with suicidal
thoughts.
Additionally, VHA requires medical centers to conduct timely disclosure of events that meet
criteria.25 Of the four root cause analyses noted above, none had evidence of institutional
disclosure. Further, the OIG requested a list of institutional disclosures from October 16, 2017,
24
VHA Directive 1190, Peer Review for Quality Management, November 21, 2018. A sentinel event is an incident
or condition that results in patient “death, permanent harm, or severe temporary harm and intervention required to
sustain life.”
25
VHA Directive 1004.08, Disclosure of Adverse Events to Patients, October 31, 2018. VHA defines an
institutional disclosure of adverse events (sometimes referred to as an “administrative disclosure”) as “a formal
process by which VA medical facility leader(s), together with clinicians and others as appropriate, inform the patient
or the patient’s personal representative that an adverse event has occurred during the patient’s care that resulted in,
or is reasonably expected to result in, death or serious injury, and provide specific information about the patient’s
rights and recourse.” VHA defines a large-scale disclosure of adverse events (sometimes referred to as a
“notification”) as “a formal process by which VHA officials assist with coordinating the notification to multiple
patients, or their personal representatives, that they may have been affected by an adverse event resulting from a
systems issue.”
VA OIG 20-01276-131 | Page 17 | May 19, 2021

through July 27, 2020, and noted that none were completed in a timely manner and that the
associated documentation in the patients’ electronic health record lacked the required reasons for
the delays. There appear to be opportunities for medical center leaders to evaluate and improve
the processes used to identify adverse patient events that warrant timely disclosure to patients.
Table 9 lists the reported sentinel events and disclosures from October 16, 2017 (the prior OIG
comprehensive healthcare inspection), through July 27, 2020.26
Table 9. Summary of Selected Organizational

Risk Factors
(October 16, 2017, through July 27, 2020)
Factor Number of
Occurrences
Sentinel Events 0
Institutional Disclosures 4
Large-Scale Disclosures 0
Source: Cincinnati VA Medical Center, Chief Quality of Quality
Management (received July 27 and July 28, 2020).
Veterans Health Administration Performance Data

The VA Office of Operational Analytics and Reporting adopted the SAIL Value Model to help
define performance expectations within VA with “measures on healthcare quality, employee
satisfaction, access to care, and efficiency.” Despite noted limitations for identifying all areas of
clinical risk, the data are presented as one way to understand the similarities and differences
between the top and bottom performers within VHA.27
Figure 5 illustrates the medical center’s quality of care and efficiency metric rankings and
performance compared with other VA facilities as of December 31, 2019. Of note, figure 5 uses
blue and green data points to indicate high performance for the Cincinnati VA Medical Center
(for example, in the areas of rating (of) specialty care (SC) provider, mental health (MH)
experience (exp) of care, and rating (of) primary care (PC) provider). Metrics that need
improvement are denoted in orange and red (for example, care transition, health care (HC)
26
It is difficult to quantify an acceptable number of adverse events affecting patients because even one is too many.
Efforts should focus on prevention. Events resulting in death or harm and those that lead to disclosure can occur in
either inpatient or outpatient settings and should be viewed within the context of the complexity of the facility. (Note
that the Cincinnati VA Medical Center is a -high complexity (1b) affiliated system as described in appendix B.)
27
“Strategic Analytics for Improvement and Learning (SAIL) Value Model,” VHA Support Service Center,
accessed March 6, 2020, https://vssc.med.va.gov. (This is an internal VA website not publicly accessible.)
VA OIG 20-01276-131 | Page 18 | May 19, 2021

associated (assoc) infections, rating (of) hospital, and healthcare effectiveness data and
information set outpatient performance measures (HEDIS like – HED90_ec)).28
Figure 5. System quality of care and efficiency metric rankings for FY 2020 quarter 1(as of
December 31, 2019).
Source: VHA Support Service Center.
Note: The OIG did not assess VA’s data for accuracy or completeness.
Veterans Health Administration Performance Data for Community

Living Centers
The “CLC SAIL” Value Model is a tool to “summarize and compare the performance of CLCs in
the VA.” The model “leverages much of the same data” used in the Centers for Medicare &
28
For information on the acronyms in the SAIL metrics, please see appendix E.
VA OIG 20-01276-131 | Page 19 | May 19, 2021

Medicaid Services’ (CMS) Nursing Home Compare and provides a single resource “to review
quality measures and health inspection results.”29
Figure 6 illustrates the medical center’s CLC quality rankings and performance compared with
other VA CLCs as of December 31, 2019. Figure 6 uses blue and green data points to indicate
high performance for the Cincinnati CLC (for example, in the areas of physical restraints–long-
stay (LS), outpatient emergency department (ED) visit–short-stay (SS), and high-risk pressure
ulcer (PU) (LS)). Metrics that need improvement are denoted in orange and red (for example,
rehospitalized after nursing home (NH) admission (SS), urinary tract infection (UTI) (LS), and
moderate-severe pain (LS)).30
Blue - 1st Quintile; Green - 2nd; Yellow - 3rd; Orange - 4th; Red - 5th Quintile.
Figure 6. Cincinnati CLC Quality Measure Rankings for FY 2020 quarter 1 (as of December 31, 2019).
LS = Long-Stay Measure SS = Short-Stay Measure
29
Center for Innovation and Analytics, Strategic Analytics for Improvement and Learning (SAIL) for Community
Living Centers (CLC), July 23, 2020. “In December 2008, The Centers for Medicare & Medicaid Services (CMS)
enhanced its Nursing Home Compare public reporting site to include a set of quality ratings for each nursing home
that participates in Medicare or Medicaid. The ratings take the form of several “star” ratings for each nursing home.
The primary goal of this rating system is to provide residents and their families with an easy way to understand
assessment of nursing home quality; making meaningful distinctions between high and low performing nursing
homes.”
30
For data definitions of acronyms in the SAIL CLC measures, please see appendix F.
VA OIG 20-01276-131 | Page 20 | May 19, 2021

Leadership and Organizational Risks Conclusion

The OIG noted that three of the four executive leadership positions were occupied by acting staff
at the time of the virtual inspection. The permanent ADPCS, who was serving as the acting
Medical Center Director, was the most tenured member of the leadership team, having served as
ADPCS since January 2019. Survey results revealed opportunities for the acting Chief of Staff to
improve employees’ attitudes toward the workplace. While patient experience survey data
indicated overall satisfaction with care, gender-specific results highlighted opportunities to
improve experiences in the inpatient and patient-centered medical home settings. However,
medical center leaders appeared to be actively engaged with patients by conducting veteran town
hall meetings and leadership rounds. The OIG’s review of selected organizational risk factors
identified concerns with processes related to identification of sentinel events and institutional
disclosure. In individual interviews, executive leaders were able to speak in depth about actions
taken during the previous 12 months to maintain or improve organizational performance,
employee satisfaction, and/or patient experiences. Additionally, the executive leaders were
generally knowledgeable within their scope of responsibilities about VHA data and/or system-
level factors contributing to specific poorly performing SAIL and CLC SAIL measures.
VA OIG 20-01276-131 | Page 21 | May 19, 2021

COVID-19 Pandemic Readiness and Response

On March 11, 2020, due to the “alarming levels of spread and severity” of COVID-19, the World
Health Organization declared a pandemic.31 VHA subsequently issued its COVID-19 Response
Plan on March 23, 2020, which presents strategic guidance on prevention of viral transmission
among veterans and staff and appropriate care for sick patients.32
During this time, VA continued providing for veterans’ healthcare needs and engaged its fourth
mission, “the provision of hospital care and medical services during certain disasters and
emergencies” to persons “who would otherwise not have eligibility to receive such care and
services.”33 “In effect, VHA facilities provide a safety net for the nation’s hospitals should they
become overwhelmed—for veterans (whether previously eligible or not) and non-veterans.”34
Due to VHA’s mission-critical work in supporting both veteran and civilian populations during
the pandemic, the OIG conducted an evaluation of the pandemic’s impact on the medical center
and its leaders’ subsequent response. The OIG analyzed performance in the following domains:
· Emergency preparedness
· Supplies, equipment, and infrastructure
· Staffing
· Access to care
· CLC patient care and operations
The OIG also surveyed medical center staff to solicit their feedback and potentially identify any
problematic trends and/or issues that may require follow-up. The results of the OIG’s evaluation
of the medical center’s COVID-19 pandemic readiness and response were compiled and reported
with other facilities in a separate publication to provide stakeholders with a more comprehensive
picture of regional VHA challenges and ongoing efforts.35
31
“WHO Director General’s Opening Remarks at the Media Briefing on COVID-19 – 11 March 2020,” World
Health Organization, accessed March 23, 2020, https://www.who.int/dg/speeches/detail/who-director-general-s-
opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020.
32
VHA Office of Emergency Management, COVID-19 Response Plan, March 23, 2020.
33
38 U.S.C § 1785. VA’s missions include serving veterans through care, research, and training. 38 C.F.R. § 17.86
outlines VA’s fourth mission for the provision of hospital care and medical services during certain disasters and
emergencies: “During and immediately following a disaster or emergency…VA under 38 U.S.C ⸹1785 may furnish
hospital care and medical services to individuals (including those who otherwise do not have VA eligibility for such
care and services) responding to, involved in, or otherwise affected by that disaster or emergency.”
34
VA OIG, OIG Inspection of Veterans Health Administration’s COVID-19 Screening Processes and Pandemic
Readiness, March 19–24, 2020, Report No. 20-02221-120, March 26, 2020.
35
VA OIG 20-01276-131 | Page 22 | May 19, 2021

Quality, Safety, and Value

VHA’s goal is to serve as the nation’s leader in delivering high-quality, safe, reliable, and
veteran-centered care.36 To meet this goal, VHA requires that its facilities implement programs
to monitor the quality of patient care and performance improvement activities and maintain Joint
Commission accreditation.37 Many quality-related activities are informed and required by VHA
directives, nationally recognized accreditation standards (such as The Joint Commission), and
federal regulations. VHA strives to provide healthcare services that compare “favorably to the
best of the private sector in measured outcomes, value, [and] efficiency.”38
To determine whether VHA facilities have implemented and incorporated OIG-identified key
processes for quality and safety into local activities, the inspection team evaluated the medical
center’s committee responsible for quality, safety, and value (QSV) oversight functions; its
ability to review data, information, and risk intelligence; and its ability to ensure that key QSV
functions are discussed and integrated on a regular basis. Specifically, OIG inspectors examined
the following requirements:
· Review of aggregated QSV data
· Recommendation and implementation of improvement actions
· Monitoring of fully implemented improvement actions
The OIG reviewers also assessed the medical center’s processes for conducting protected peer
reviews of clinical care.39 Protected peer reviews, “when conducted systematically and credibly,”
reveal areas for improvement (involving one or more providers’ practices) and can result in both
immediate and “long-term improvements in patient care.”40 Peer reviews are “intended to
promote confidential and non-punitive processes” that consistently contribute to quality
management efforts at the individual provider level.41 The OIG team examined the completion of
the following elements:
36
Department of Veterans Affairs, Veterans Health Administration Blueprint for Excellence, September 21, 2014.
37
VHA Directive 1100.16, Accreditation of Medical Facility and Ambulatory Programs, May 9, 2017.
38
Department of Veterans Affairs, Veterans Health Administration Blueprint for Excellence.
39
VHA Directive 1190, Peer Review for Quality Management, November 21, 2018. A peer review is a “critical
review of care, performed by a peer,” to evaluate care provided by a clinician for a specific episode of care, identify
learning opportunities for improvement, provide confidential communication of the results back to the clinician, and
identify potential system or process improvements. In the context of protected peer reviews, “protected” refers to the
designation of review as a confidential quality management activity under 38 U.S.C. 5705 as “a Department
systematic health-care review activity designated by the Secretary to be carried out by or for the Department for
improving the quality of medical care or the utilization of health-care resources in VA facilities.”
40
VHA Directive 1190.
41
VHA Directive 1190.
VA OIG 20-01276-131 | Page 23 | May 19, 2021

· Evaluation of aspects of care (for example, choice and timely ordering of diagnostic
tests, prompt treatment, and appropriate documentation)
· Peer review of all applicable deaths within 24 hours of admission to the hospital
· Peer review of all completed suicides within seven days after discharge from an
inpatient mental health unit42
· Completion of final reviews within 120 calendar days
· Implementation of improvement actions recommended by the Peer Review
Committee
· Quarterly review of the Peer Review Committee’s summary analysis by the
Executive Committee of the Medical Staff
Next, the inspection team assessed the medical center’s utilization management (UM) program, a
key component of VHA’s framework for quality, safety, and value, which provides vital tools for
managing the quality and the efficient use of resources.43 It strives to ensure that the right care
occurs in the right setting, at the right time, and for the right reason using evidence-based
practices and continuous measurement to guide improvements.44 Inspectors reviewed several
aspects of the UM program:
· Completion of at least 80 percent of all required inpatient reviews
· Documentation of at least 75 percent of physician UM advisors’ decisions in the
National UM Integration database
· Interdisciplinary review of UM data
· Implementation and monitoring of improvement actions recommended by the
interdisciplinary UM group
Finally, the OIG reviewers assessed the medical center’s reports of patient safety incidents with
related root cause analyses.45 Among VHA’s approaches for improving patient safety is the
mandated reporting of patient safety incidents to its National Center for Patient Safety. Incident
reporting helps VHA learn about system vulnerabilities and how to address them. Required root
42
VHA Directive 1190.
43
VHA Directive 1117(2), Utilization Management Program, July 9, 2014, amended April 30, 2019. UM reviews
include evaluating the “appropriateness, medical need, and the efficiency of health care services according to
evidence-based criteria.” (This directive was rescinded and replaced with VHA Directive 1117, Utilization
Management Program, October 8, 2020.)
44
VHA Directive 1117(2).
45
VHA Handbook 1050.01, VHA National Patient Safety Improvement Handbook, March 4, 2011. A root cause
analysis is “a process for identifying the basic or contributing causal factors that underlie variations in performance
associated with adverse events or close calls.”
VA OIG 20-01276-131 | Page 24 | May 19, 2021

cause analyses help to more accurately identify and rapidly communicate potential and actual
causes of harm to patients throughout the medical center.46 The medical center was assessed for
its performance on several dimensions:
· Annual completion of a minimum of eight root cause analyses47
· Inclusion of required content in root cause analyses
· Submission of completed root cause analyses to the National Center for Patient
Safety within 45 days
· Provision of feedback about root cause analysis actions to reporting employees
· Submission of an annual patient safety report to medical center leaders
The OIG reviewer interviewed senior managers and key QSV employees and evaluated meeting
minutes, protected peer reviews, root cause analyses, the annual patient safety report, and other
relevant documents.48
Quality, Safety, and Value Findings and Recommendations

The medical center complied with requirements for the establishment of a committee responsible
for QSV oversight functions, completion of UM reviews, and submission of the annual patient
safety report. However, the OIG identified weaknesses in the QSV Committee’s implementation
of improvement actions, protected peer reviews, and root cause analysis processes.49
VHA requires that facilities achieve and maintain TJC accreditation. TJC standards specify that
facilities establish a governing body responsible for QSV oversight functions and practices. The
governing body reviews relevant data and information and ensures that when actions are
recommended by the committee, they are fully implemented and changes are monitored.50 The
OIG reviewed meeting minutes from January through December 2019 and found the QSV
Committee, which was responsible for tracking and trending quality of care and patient
outcomes, did not consistently implement action items. This could have resulted in insufficient
46
VHA Handbook 1050.01.
47
VHA Handbook 1050.01. “The requirement for a total of eight RCAs [root cause analyses] and Aggregated
Reviews is a minimum number, as the total number of RCAs is driven by the events that occur and the SAC [Safety
Assessment Code] score assigned to them…At least four analysis per fiscal year must be individual RCAs, with the
balance being Aggregated Reviews or additional individual RCAs.”
48
For CHIP visits, the OIG selects performance indicators based on VHA or regulatory requirements or
accreditation standards and evaluates these for compliance.
49
At the time of the OIG review, the committee was called the QSV Committee. The medical center subsequently
changed the name to the Quality and Patient Safety Council which is reflected in the action plans and updated in
figure 4.
50
VHA Directive 1100.16, Accreditation of Medical Facility and Ambulatory Programs, May 9, 2017; TJC.
Leadership standards LD.01.01.01, LD.02.01.01, and LD.03.01.01.
VA OIG 20-01276-131 | Page 25 | May 19, 2021

oversight of needed patient safety and quality of care improvements. The Chief of Quality
Management stated that a separate spreadsheet was kept to track actions but it was not included
in the QSV Committee minutes or agenda.
Recommendation 1
1. The Medical Center Director evaluates and determines any additional reasons for
noncompliance and ensures the Quality, Safety, and Value Committee fully
implements and monitors improvement actions.51
Medical Center concurred.
Target date for completion: Completed
Medical Center response: The Quality and Patient Safety (QPS) Council Action Grid was made
as a standing agenda item on the QPS council agenda beginning September 2020. The agenda
items are reviewed by the committee at the beginning of the meeting and action grid noted in the
minutes. Talking points for the open items have also been added to the agenda of related open
action items for visibility and as a discussion reminder beginning with the October 2020 QPS
meeting. The Action Grid is used to document progress and closure of action items when they
are due to be addressed by the subject matter experts. Tracking of action items from the
September 2020 meeting through March 2021 demonstrated 6 closed actions and 11 actions still
being implemented towards closure.
VHA requires peer review for all deaths “within 24 hours of admission (except in cases when
death is anticipated and clearly documented, such as transfer from hospice care)” and completed
suicides occurring within seven days after discharge from an inpatient mental health or
residential care facility.52 The OIG found that between January 1 and December 31, 2019, two
applicable deaths were not evaluated to determine if peer review was warranted.53 This may have
prevented timely identification of inconsistencies in healthcare providers’ practices or the
opportunity to identify systemic issues. The Chief of Quality Management could not provide a
reason for the lack of evaluation.
51
The OIG reviewed evidence sufficient to demonstrate that the medical center had completed improvement actions
and therefore closed the recommendation before publication of the report.
52
VHA Directive 1190.
53
Two deaths occurred within 24 hours of admission.
VA OIG 20-01276-131 | Page 26 | May 19, 2021

Recommendation 2
2. The Chief of Staff determines the reasons for noncompliance and makes certain that
all applicable deaths are peer reviewed.54
Medical center concurred.
Medical center response: A tracking system of mortality reviews had not been maintained on the
Quality-shared drive. The Risk Manager is responsible to complete and track mortality reviews.
A report is pulled at least monthly to determine deaths within 24 hours of admission. These are
reviewed for peer review appropriateness. These mortalities reviews are documented on a
spreadsheet and stored on the Quality share drive for availability. The number of deaths within
24 hours of admissions and the number reviewed for peer review appropriateness are
documented on a spreadsheet and uploaded to the VISN quarterly. There has been one mortality
within 24 hours from October 2020-March 2021 and it has been reviewed for peer review
appropriateness. 1/1 (100%) compliance.
Any suicides which occur within seven days after discharge from an inpatient mental health or
residential care are monitored through issues briefs from the suicide prevention coordinator and
noted on the mortality spreadsheet. Currently since June 2020-March 2021, no suicides fell into
this category.
Completed mortality and suicide reviews are included in the quarterly peer review trends report
presented to CEB [Clinical Executive Board] each quarter.
VHA required the Medical Center Director to ensure that an interdisciplinary group to review
UM data was established. This group must have included, but was not limited to,
“representatives from UM, medicine, nursing, social work, case management, mental health, and
CBO-R-UR [chief business office revenue-utilization review].”55 The OIG found that between
February and December 2019, there was no interdisciplinary team reviewing UM data. On
October 8, 2020, VHA updated the requirement for the review of UM data to be performed by “a
multidisciplinary committee, which may include representatives from” various services.56
Therefore, the OIG made no recommendation.
For thoroughness and credibility, VHA requires root cause analyses to include several factors.
These include participation by leaders, “analysis of the underlying systems…to determine where
redesigns might reduce risk,” “determination of potential improvement in processes or systems
54
55
56
VHA Directive 1117, Utilization Management Program, October 8, 2020.
VA OIG 20-01276-131 | Page 27 | May 19, 2021

that would tend to decrease the likelihood” of future events, identification of “at least one root
cause with a corresponding action and outcome measure,” and feedback on action(s) taken
(resulting from the root cause analysis) provided to the reporter of the adverse event or close call.
Once corrective actions are implemented, monitoring must be conducted to assess for
effectiveness.57
Of the five root cause analyses reviewed, the OIG found that none included an analysis of the
underlying systems, and three did not address the determination of potential improvement
processes that would decrease the likelihood of future events. Three of the five root cause
analyses lacked evidence that action items were fully implemented.
When root cause analyses are not thorough and credible, the process to identify vulnerabilities
and implement improvements to prevent future patient harm may be impacted. The Patient
Safety Manager could not provide a reason for noncompliance. The Patient Safety Manager
reported that the determination of potential improvement processes was implicit in the root cause
statement, and lack of monitoring outcome measures for one root cause analysis was due to a
documentation flaw. The Patient Safety Manager also reported not fully understanding that the
series of “why” questions were to be documented in WebSPOT when these reviews were
completed.
Recommendation 3
noncompliance and ensures that root cause analyses include all required review
elements.58
Medical Center concurred.
Medical Center response: The root cause analyses (RCA) were completed and shared during
RCA report out to leadership, however, not all required items were documented into WebSPOT.
All required items for RCAs and documentation into WebSPOT has been completed as required
based upon Patient Safety Managers’ peer to peer audits of each RCA. This audit process began
with new RCAs after May 2020 to ensure documentation completeness in WebSPOT. Audit
demonstrates 7/7 (100%) compliance for RCAs having all required elements from June 2020-
March 2021. The results of this audit period have been shared with the Interim Medical Center
Director and at the April 13, 2021 Quality and Patient Safety Council.
57
58
VA OIG 20-01276-131 | Page 28 | May 19, 2021

Medical Staff Privileging

VHA has defined procedures for the clinical privileging of “all healthcare professionals who are
permitted by law and the facility to practice independently”—“without supervision or direction,
within the scope of the individual’s license, and in accordance with individually-granted clinical
privileges.” These healthcare professionals are also referred to as licensed independent
practitioners (LIPs).59
Clinical privileges need to be specific and based on the individual practitioner’s clinical
competence. They are recommended by service chiefs and the Executive Committee of the
Medical Staff and approved by the Director. Clinical privileges are granted for a period not to
exceed two years, and LIPs must undergo reprivileging prior to their expiration.60
VHA defines the focused professional practice evaluation (FPPE) as “a time-limited period
during which the medical staff leadership evaluates and determines the practitioner’s
professional performance.” The FPPE process occurs when a provider is hired at the facility and
granted initial privileges and before any new clinical privileges are granted. Additionally, VA
facilities must continuously monitor the performance of their providers. VHA requirements state
that “the on-going monitoring of privileged practitioners, Ongoing Professional Practice
Evaluation (OPPE), is essential to confirm the quality of care delivered.” 61 The OIG examined
various requirements for FPPEs and OPPEs:
· FPPEs
o Establishment of criteria in advance
o Use of minimum criteria for selected specialty LIPs62
o Clear documentation of the results and time frames
o Evaluation by another provider with similar training and privileges
· OPPEs
o Application of criteria specific to the service or section
o Use of minimum criteria for selected specialty LIPs63
o Evaluation by another provider with similar training and privileges
59
VHA Handbook 1100.19, Credentialing and Privileging, October 15, 2012.
60
61
62
VHA Acting Deputy Under Secretary for Health for Operations and Management (DUSHOM) Memorandum,
Requirements for Peer Review of Solo Practitioners, August 29, 2016.
63
VHA Acting DUSHOM Memorandum, Requirements for Peer Review of Solo Practitioners.
VA OIG 20-01276-131 | Page 29 | May 19, 2021

The OIG determined whether service chiefs recommended continuing the LIPs’ current
privileges based in part on the results of OPPE activities and if the medical center’s Executive
Committee of the Medical Staff decided to recommend continuing privileges based on FPPE and
OPPE results.
VA must put processes in place to reasonably ensure that its healthcare staff meet or exceed
professional practice standards for delivering patient care. When there is a serious concern
regarding a current or former licensed practitioner’s clinical practice, VA has an obligation to
notify state licensing boards and subsequently respond to inquiries from state licensing boards
concerning the licensed practitioner’s clinical practice.64 Further, “VA medical facility Directors
must designate an individual, and backup, to be responsible for the SLB [state licensing board]
reporting process. This individual will be the subject matter expert (SME) for the facility…and
ensure oversight of the exit review process, including receipt, review, and maintenance of the
Provider Exit Review Forms.”65 The OIG reviewers assessed whether the medical center’s staff
· Designated an individual and backup responsible for the state licensing board
reporting process,
· Completed forms within the required time frame and with required oversight, and
· Reported results to state licensing boards when indicated.
To determine whether the medical center complied with requirements, the OIG interviewed key
managers and selected and reviewed the privileging folders of several medical staff members:
· Five solo/few practitioners who underwent initial or reprivileging during calendar year
201966
· Ten LIPs who completed an FPPE in calendar year 2019
· Ten LIPs privileged during calendar year 2019
· Twenty LIPs who left the medical center in calendar year 2019
64
VHA Handbook 1100.18, Reporting and Responding to State Licensing Boards, December 22, 2005. (This
handbook was replaced on January 28, 2021, with VHA Directive 1100.18. The two documents contain similar
language related to state licensing board requirements.)
65
VHA Notice 2018-05, Amendment to VHA Handbook 1100.18, Reporting and Responding to State Licensing
Boards, February 5, 2018. (VHA Directive 1100.18 requires the “Credentialing and Privileging program manager to
be responsible for the [state licensing board] reporting process and oversight of timely completion of exit reviews.”
The new directive also revises the requirement for exit review forms to be completed within seven calendar days to
seven business days.)
66
VHA Acting DUSHOM Memorandum, Requirements for Peer Review of Solo Practitioners. This memorandum
refers to a solo practitioner as being one provider in the facility that is privileged in a particular specialty. The OIG
considers few practitioners as being less than three providers in the facility that are privileged in a particular
specialty.
VA OIG 20-01276-131 | Page 30 | May 19, 2021

Medical Staff Privileging Findings and Recommendations

The OIG identified deficiencies with FPPE, OPPE, and provider exit review processes. During
the review of FPPEs, the OIG also noted that one practitioner received an expedited appointment
to the medical staff. VHA acknowledges that “there may be instances where expediting a
medical staff appointment for LIPs is in the best interest of quality patient care.”67 The Medical
Staff Coordinator explained that this type of appointment allows the practitioner to see patients
before the credentialing request is approved by the Clinical Executive Board. However, the OIG
did not find an urgent need for the practitioner to be appointed in this manner and circumvent the
standard credentialing process. The acting Chief of Staff confirmed that expedited credentialing
was completed only because the provider transferred from another VA.
VHA requires the criteria for the FPPE process “to be defined in advance, using objective criteria
accepted by the practitioner.” VHA also requires that FPPE results be documented in the
provider’s profile.68 The OIG reviewed six LIP profiles and found that all lacked evidence that
the practitioners were aware of the evaluation criteria before clinical managers initiated the FPPE
process. This could have caused LIPs to misunderstand FPPE expectations. The acting Chief of
Medicine acknowledged that due to lack of oversight, none of the prior FPPEs included
documentation of the practitioner accepting the criteria in advance of the process.
Recommendation 4
4. The Chief of Staff determines the reasons for noncompliance and ensures clinical
managers define in advance, communicate, and document criteria for focused
professional practice evaluations in practitioner profiles.
Target date for completion: December 31, 2021
Medical center response: The FPPE form will include the evaluation criteria and an
acknowledgment of the discussion of the evaluation criteria for the initial FPPE between the
provider and supervisor. An audit of all (100%) new provider FPPEs will be audited for 6
consecutive months. Evidence of evaluation criteria for FPPE and practitioner’s awareness prior
to the FPPE process will be achieved with a target of 90% compliance rate. Compliance will be
reported at CEB.
VHA uses the FPPE process as an oversight tool and requires FPPEs to be completed “when a
practitioner does not have the documented evidence of competent performance of the privileges
requested.” The FPPE must be time-limited and may include “periodic chart review, direct
67
68
VA OIG 20-01276-131 | Page 31 | May 19, 2021

observation, monitoring of diagnostic and treatment techniques, or discussion with other

individuals involved in the care of patients.” Additionally, results of the review “must be
documented in the practitioner’s provider profile and reported to the Executive Committee of the
Medical Staff.”69
In three of six LIP profiles, the OIG did not find evidence of FPPE results. During the course of
the review, the OIG also noted that four low-volume practitioners, who had been on staff at the
medical center between five and eight months, had no FPPEs completed at the time of the
inspection. When FPPEs are not conducted—or not documented—it may result in practitioners
providing patient care without a thorough review of their clinical competencies, which could
impact quality care and patient safety. The acting Chief of Medicine was not able to provide a
reason for the lack of FPPE results but reported that the four noted LIPs were hired to support
staffing when needed, had not begun providing patient care, and were never started on the
evaluation process. This is a repeat finding from the previous inspection.70
Recommendation 5
5. The Chief of Staff evaluates and determines additional reasons for noncompliance
and ensures that service chiefs document the results of focused professional practice
evaluations in practitioner profiles.
Medical center response: FPPE forms will have the documented results of the FPPE evaluation
along with the provider and supervisor acknowledgment of the review. An audit of all (100%)
new provider FPPEs will be audited for 6 consecutive months with a 90% target of documented
results and acknowledgment of review on the FPPE form. Compliance will be reported at CEB.
VHA requires that, at the time of reprivileging, service chiefs consider relevant, service- and
practitioner-specific data using defined criteria when recommending the continuation of LIP
privileges to the Executive Committee of the Medical Staff (known as the Clinical Executive
Board at this medical center).71 Such data are maintained as part of the practitioner’s profile and
may include “direct observation, clinical discussions, and clinical pertinence reviews.”72
69
70
VA OIG, Comprehensive Healthcare Inspection Program Review of the Cincinnati VA Medical Center,
Cincinnati, Ohio, Report No. 17-05398-172, May 23, 2018. The previous recommendation was closed when
medical center leaders submitted evidence of sustained improvement, but the OIG team found continued issues that
warranted a repeat recommendation for improvement.
71
72
VA OIG 20-01276-131 | Page 32 | May 19, 2021

The OIG found that two provider profiles did not contain evidence of either service-specific
OPPE data or the service chief’s recommendation to continue privileges based in part on OPPE
activities. One additional provider’s profile lacked evidence of service-specific OPPE data while
one other provider’s profile lacked evidence that the service chief recommended privileges based
in part on the OPPE activities. This resulted in incomplete data to support decisions to continue
clinical privileges. The Medical Staff Coordinator stated that although service chiefs were
educated on the need to include service-specific elements in OPPEs, not all followed the
requirements. The acting Chief of Staff was unable to provide a clear reason for the challenges
with the OPPE process. Service-specific OPPE data is a repeat finding from the previous
inspection.73
Recommendation 6
and ensures that service chiefs collect service-specific ongoing professional practice
evaluation data.
Medical center response: Service specific data for OPPEs and service chief recommendation to
continue privileges based upon the OPPE activities will be documented on the OPPE forms prior
to review and consideration by the CEB. An audit of 30 random OPPEs will be performed
monthly for 6 consecutive months. A compliance rate for service chiefs’ service-specific OPPE
evaluation data documented on the OPPE will be 90%. Compliance will be reported at CEB.
Recommendation 7
7. The Chief of Staff determines the reasons for noncompliance and ensures service
chiefs recommend continuation of privileges based on ongoing professional practice
evaluation data.
73
VA OIG, Comprehensive Healthcare Inspection Program Review of the Cincinnati VA Medical Center,
Cincinnati, Ohio, May 23, 2018. The previous recommendation was closed when medical center leaders submitted
evidence of sustained improvement, but the OIG team found continued issues that warranted a repeat
recommendation for improvement.
VA OIG 20-01276-131 | Page 33 | May 19, 2021


Medical center response: Service chief recommendation to continue privileges based upon the
OPPE activities will be documented on the OPPE forms prior to review and consideration by the
CEB. An audit of 30 random OPPEs will be performed monthly for 6 consecutive months. A
compliance rate of service chiefs recommendation for continuation of privileges based upon
OPPE evaluation data will be 90%. Compliance will be reported at CEB.
VHA requires that FPPE and OPPE results be reported to the Executive Committee of the
Medical Staff for review and evaluation of LIPs’ initial and reprivileging requests. Committee
minutes must indicate the materials reviewed and the rationale for the privileging determinations.
The committee’s recommendation is then submitted to the Medical Center Director for
approval.74
For three of the six practitioners who were granted initial privileges, the OIG did not find
evidence that the Clinical Executive Board documented its decision to recommend continuing
privileges based upon FPPE activities. Additionally, three had incomplete documentation to
support the Clinical Executive Board’s decision to recommend privileges based on OPPE results.
Failure to use FPPE and OPPE data and document the rationale for recommendations may result
in incomplete evidence to support the Director’s approval of clinical privileges. The acting Chief
of Medicine reported that each service provides OPPE results to the Clinical Executive Board
twice per year and conceded it was possible that a practitioner was not listed on the agenda, or
the results were not captured in the minutes, due to the high volume of practitioners discussed.
Recommendation 8
and makes certain that Clinical Executive Board meeting minutes consistently
reflect the review of professional practice evaluation results in the decision to
recommend initiation and continuation of privileges.
74
VA OIG 20-01276-131 | Page 34 | May 19, 2021


Medical center response: The CEB meeting minutes will consistently reflect the review of
professional practice evaluation results in the decision to recommend initiation and continuation
of privileges during time of appointment and reappointment of providers based upon
FPPE/OPPE documented activities/data. An audit of 30 random FPPE/OPPEs for initial
appointment or reappointment for privileges will be performed monthly for 6 consecutive
months with a 90% target. The review will include accurate documentation in the meeting
minutes reflecting CEB review and decision based upon FPPE/OPPE activities/data. Compliance
will be reported at CEB.
VHA required the “Director, or head,” to ensure that exit review forms, which document the
review of practitioners’ clinical practice, are “completed within 7 calendar days of departure of
any licensed health care professional.”75 VHA changed the requirement to seven business days in
January 2021.76 Of the 20 practitioners who departed the medical center in calendar year 2019,
the OIG found that 18 had a completed exit form; however, nine of those were not completed
within seven business days. Failure to complete exit review forms in a timely manner may delay
reporting of practitioners’ potential substandard care to state licensing boards. The Medical Staff
Coordinator reported that medical center leaders had become aware of the problematic exit
review processes, noting the exit forms were not completed due to lack of oversight. The
Medical Staff Coordinator stated that each service line now maintains the Provider Exit Form,
receives reminders from credentialing staff, and completes the forms electronically with digital
signatures/time stamps.
Recommendation 9
noncompliance and makes certain that provider exit review forms are completed
within seven business days of licensed healthcare professionals’ departure from the
medical center.
75
VHA Notice 2018-05; VHA Handbook 1100.18, Reporting and Responding to State Licensing Boards, December
22, 2005. VHA Handbook 1100.18 was replaced with VHA Directive 1100.18 on January 28, 2021. The new
directive changed the requirement from seven calendar days to seven business days.
76
VHA Directive 1108.18, Reporting and Responding to State Licensing Boards, January 28, 2021.
VA OIG 20-01276-131 | Page 35 | May 19, 2021


Medical center response: The Credentialing and Privileging Office has been added to the facility
clearance checklist for all licensed professionals. A line item has also been added to the
clearance form for the supervisor to initiate and check off that the provider exit review has been
initiated. The policy for employee clearance was updated March 2021 which includes the 7-day
requirement. An audit of exit reviews completed within 7 business days will be completed for 6
consecutive months for a 90% compliance rate. Compliance will be reported at CEB.
VA OIG 20-01276-131 | Page 36 | May 19, 2021

Medication Management: Long-Term Opioid Therapy for Pain

Opioid medications are known to cause dependence, tolerance, abuse, and accidental overdose.77
The opioid crisis is a national public health emergency with, on average, 130 Americans dying
every day from an opioid overdose.78 Long-term opioid use is of particular concern in the veteran
population where there is a high incidence of posttraumatic stress disorder, major depressive
disorder, alcohol use, substance abuse, and suicide attempts.79 These disorders, coupled with
high-dose opioid use, can potentially lead to an increased risk of overdose compared to the
general population.80
VHA requires routine assessments of pain and the completion of an opioid risk assessment
before initiating patients on long-term opioid therapy and recommends against the therapy for
patients with untreated substance use disorders. VHA also recommends avoiding drugs capable
of inducing fatal interactions, such as opioids with benzodiazepines.81 Healthcare providers are
required to conduct initial and random ongoing urine drug testing during opioid therapy.82 To
achieve VHA’s vision of providing patient-driven healthcare, providers are also required to
obtain informed consent from patients and to provide education about the risks, benefits, and
alternatives prior to initiating long-term opioid therapy.83 VHA recommends evaluating patients
receiving continued opioid therapy for improvement of pain and opioid-related adverse events at
least every three months and more frequently as doses increase.84
The OIG reviewers assessed providers’ provision of pain management using long-term opioid
therapy:
· Completion of initial screening for pain
· Assessment of aberrant behavior risk
· Avoidance of concurrent therapy with benzodiazepines
· Completion of urine drug testing with intervention, when indicated
77
“Information Sheet on Opioid Overdose,” World Health Organization, accessed November 6, 2019,
https://www.who.int/substance_abuse/information-sheet/en/.
78
“Opioid Overdose: Understanding the Epidemic,” Centers for Disease Control and Prevention, accessed
November 6, 2019, https://www.cdc.gov/drugoverdose/epidemic.
79
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain, Version 3.0. February 2017.
80
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain.
81
“Benzodiazepines, Street Names: Benzos, Downers, Nerve Pills, Tranks,” U.S. Drug Enforcement
Administration, accessed December 1, 2019, https://www.deadiversion.usdoj.gov/drug_chem_info/benzo.pdf.
Benzodiazepines “are a class of drugs that produce central nervous system (CNS) depression and that are most
commonly used to treat insomnia and anxiety.”
82
83
VHA Directive 1005, Informed Consent for Long-Term Opioid Therapy for Pain, May 13, 2020.
84
VA OIG 20-01276-131 | Page 37 | May 19, 2021

· Documentation of informed consent

· Timely follow-up with patients included required elements
VHA also requires facilities to establish a multidisciplinary pain management committee “to
provide oversight, coordination, and monitoring of pain management activities and processes.”
Monitoring measures include, but are not limited to, “adherence to published clinical practice
guidelines, timeliness of pain treatment, adequacy of pain control, medication safety, appropriate
use of stepped care treatment…patient satisfaction, physical and psychosocial functioning, and
quality of life.”85 The OIG examined indicators for program oversight and evaluation:
· Performance of pain management committee activities
· Monitoring of quality measures
· Following the quality improvement process
The OIG interviewed key employees and managers and reviewed relevant documents and the
electronic health records of nine selected outpatients who had newly-dispensed (no VA
dispensing in previous six months) long-term opioids for pain, daily or intermittently for 90 or
more calendar days through VA from July 1, 2018, through June 30, 2019. The team considered
whether providers acted in accordance with guidelines for the provision of pain management and
the medical center’s oversight process for evaluating pain management outcomes and quality.
Medication Management Findings and Recommendations

The medical center was generally compliant with indicators of expected performance for pain
screening, aberrant behavior risk assessment, urine drug testing, and multidisciplinary pain
management committee processes. However, the OIG found a deficiency with informed consent.
VHA requires providers to obtain and document informed consent prior to initiating long-term
opioid therapy. VHA also recommends that the informed consent conversation cover the risks
and benefits of opioid therapy, as well as alternative therapies.86 The OIG did not find evidence
that clinicians documented informed consent prior to initiating long-term opioid therapy in three
of nine patient electronic health records reviewed. These patients may have received treatment
without knowledge of the risks associated with long-term opioid therapy, including opioid
dependence, tolerance, addiction, and intentional or unintentional fatal overdose. The acting
Chief of Rehabilitation Care Line reported that compliance for consent was reviewed about five
years ago with some noted improvement. However, the acting chief acknowledged that primary
care and community-based outpatient clinic provider turnover had negatively impacted
compliance; while a recent quarterly report had shown improvement in completion of informed
85
VHA Directive 2009-053, Pain Management, October 28, 2009.
86
VHA Directive 1005.
VA OIG 20-01276-131 | Page 38 | May 19, 2021

consent, the acting chief also acknowledged that the consent process needed refining. Due to the
small sample size of patient records available for review, the OIG made no recommendation.
VA OIG 20-01276-131 | Page 39 | May 19, 2021

Mental Health: Suicide Prevention Program

Suicide prevention remains a top priority for VHA. Suicide is the 10th leading cause of death,
with over 47,000 lives lost across the United States in 2019.87 The suicide rate for veterans was
1.5 times greater than for nonveteran adults and estimated to represent approximately 13.8
percent of all suicide deaths in the United States during 2018. However, suicide rates among
veterans who recently used VHA services decreased by 2.4 percent between 2017 and 2018.88
VHA has identified suicide prevention as a top priority and implemented various evidence-based
approaches to reduce the veteran suicide rate. In addition to expanded mental health services and
community outreach, VHA has developed comprehensive screening and assessment processes to
identify at-risk patients.89
VHA requires that each medical center and very large community-based outpatient clinic
(CBOC) have a full-time suicide prevention coordinator (SPC) to track and follow up with high-
risk veterans, develop a process for responding to referrals from hotlines such as the Veteran
Crisis Line, and conduct community outreach activities.90 The OIG examined various
requirements related to SPCs:
· Assignment of a full-time SPC
· Tracking and follow-up of high-risk veterans
o Patients’ completion of four appointments within the required time frame
o Safety plan completion within the required time frame
o Mental health teams’ contacts with patients for missed appointments
· Provision of suicide prevention training for nonclinical employees at new employee
orientation
· Completion of at least five outreach activities per month
VHA also requires that any patient determined to be at high risk for suicide be added to the
facility high-risk list and have a High Risk for Suicide (HRS) Patient Record Flag (PRF) placed
87
“Preventing Suicide,” Centers for Disease Control and Prevention, accessed December 9, 2020,
https://www.cdc.gov/violenceprevention/suicide/fastfact.html.
88
VA Office of Mental Health and Suicide Prevention, 2020 National Veteran Suicide Prevention Annual Report,
November 2020.
89
VA Office of Mental Health and Suicide Prevention, VA Office of Mental Health and Suicide Prevention
Guidebook, June 2018.
90
VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, September 11,
2008, amended November 16, 2015. “Very large CBOCs are those that serve more than 10,000 unique veterans each
year.” The Veterans Crisis Line connects veterans with qualified responders through a confidential toll-free hotline,
online chat, and text-messaging service to receive confidential support 24 hours a day. Community outreach
activities are described in VHA Handbook 1160.01.
VA OIG 20-01276-131 | Page 40 | May 19, 2021

in his or her electronic health record “as soon as possible but no later than 1 business day after
such determination by the SPC.”91 According to VHA, “Some studies indicate that up to two-
thirds of patients who commit suicide have seen a physician in the month before their
death…The primary purpose of the High Risk for Suicide PRF is to communicate to VA staff
that a veteran is at high risk for suicide and the presence of a flag should be considered when
making treatment decisions.”92 The HRS PRF is reviewed at least every 90 days and depending
on changes to the suicide risk status, will remain active or be removed.93 Additionally, VHA
requires designated high-risk patients to have a completed suicide safety plan and four face-to-
face visits with an acceptable provider within the first 30 days of designation. 94
The OIG noted that from July 1, 2018, to June 30, 2019 (the time frame for this retrospective
review), VHA required that “Any patient determined to be High Risk for Suicide [by the licensed
independent provider] must have a[n] HRS Flag placed in his or her chart as soon as possible but
no later than 24 hours after such determination.”95 However, on January 16, 2020, the Deputy
Undersecretary for Health for Operations and Management changed the requirement for the HRS
PRF placement to be “as soon as possible but no later than 1 business day after determination by
the SPC.”96 VHA further provided additional clarifying information:
· The “SPC exclusively controls the HRS-PRF and must limit their use to patients who
meet the criteria of being placed on the facility high-risk suicide list.”
· “The time frame of placing the flag begins once the SPC makes the determination that an
HRS-PRF is warranted.”
· The SPC’s determination process “may be beyond 24 hours after a referral, due to case
consultation and review.”97
The OIG is concerned that the updated requirement may result in delayed placement of HRS
PRFs for at-risk patients. Without defined time frames for SPC determination that the HRS PRF
91
VHA DUSHOM Memorandum, Update to High Risk for Suicide Patient Record Flag Changes, January 16, 2020.
92
VHA Directive 2008-036, Use of Patient Record Flags to Identify Patients at High Risk for Suicide,
July 18, 2008.
93
VA’s Integrated Approach to Suicide Prevention: Ready Access to Quality Care, Suicide Prevention Coordinator
Guide, January 5, 2018; VHA DUSHOM Memorandum, High Risk for Suicide Patient Record Flag Changes,
October 3, 2017.
94
VA Manual, Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version, August 20, 2008. A safety
plan is a “written list of coping strategies and sources of support that patients can use during or preceding suicidal
crises.” Face-to-face visits may be performed as telephone visits if requested by the patient. The requirement for
four face-to-face visits within 30 days of designation can be found in VA’s Integrated Approach to Suicide
Prevention: Ready Access to Quality Care, Suicide Prevention Coordinator Guide.
95
VHA DUSHOM Memorandum, High Risk for Suicide Patient Record Flag Changes, October 3, 2017.
96
VHA DUSHOM Memorandum, Update to High Risk for Suicide Patient Record Flag Changes, January 16, 2020.
97
VHA, response to questions by VA OIG Office of Healthcare Inspections from February 12, 2020, received
February 19, 2020.
VA OIG 20-01276-131 | Page 41 | May 19, 2021

is warranted, patients identified as at-risk for suicide could have flags placed in their charts
several days after referral. For example, the current requirement would allow for a patient to be
identified as high risk for suicide and referred to the SPC on Monday, the SPC to assess the
patient for risk and determine the need for an HRS PRF on the following Friday, and the SPC to
place an HRS PRF on the subsequent Monday (a week after referral).
On March 27, 2020, VHA also updated existing policy requirements to allow the review of an
HRS PRF to “occur no earlier than 10 days before and no later than 10 days after the 90-day due
date.”98
Inspectors examined the completion of several requirements:
· Review of HRS PRFs within the required time frame
· Completion of at least four mental health visits within 30 days of HRS PRF
placement
· Appropriate follow-up for no-show high-risk appointments
· Completion of suicide safety plans with the required elements within the required
time frame
All VHA employees must complete suicide risk and intervention training within 90 days of
entering their position. Clinical staff (including physicians, psychologists, dentists, registered
nurses, physician assistants, pharmacists, social workers, case managers, and Vet Center
counselors) must complete Suicide Risk Management Training for Clinicians, and nonclinical
staff must complete Operation S.A.V.E. training.99 VHA also requires that all staff receive
annual refresher training.100 In addition, suicide prevention coordinators are required to provide
in-person Operation S.A.V.E. training as part of orientation for nonclinical employees. 101
To determine whether the medical center complied with OIG-selected suicide prevention
program requirements, the inspection team interviewed key employees and reviewed
· Relevant documents;
98
VHA Notice 2020-13, Inactivation Process for Category I High Risk for Suicide Patient Record Flags,
March 27, 2020.
99
Operation S.A.V.E. is a VA gatekeeper training program provided by suicide prevention coordinators to veterans
and those who serve veterans. The acronym “S.A.V.E” summarizes the steps needed to take in recognizing and
responding to a veteran in suicidal crisis. The training was designed for nonclinical employees and includes food
service workers, registration clerks, volunteers, and police. It should also be viewed by ancillary/support staff or any
other category not covered by the clinical training.
100
VHA Directive 1071, Mandatory Suicide Risk and Intervention Training for VHA Employees,
December 22, 2017.
101
VHA DUSHOM Memorandum, Suicide Awareness Training, April 11, 2017. The training was designed for
nonclinical employees and includes food service workers, registration clerks, volunteers, and police. It should also
be viewed by ancillary/support staff or any other category not covered by the clinical training.
VA OIG 20-01276-131 | Page 42 | May 19, 2021

· The electronic health records of 36 outpatients whose electronic health records were
flagged as high risk for suicide from July 1, 2018, to June 30, 2019; and
· Staff training records.
Mental Health Findings and Recommendations

The medical center generally complied with requirements associated with a designated SPC,
suicide prevention training, and monthly outreach activities. However, the OIG found
deficiencies.
With VHA’s original requirement that was in place when these patients received care—that
“Any patient determined to be High Risk for Suicide must have a[n] HRS Flag placed in his or
her chart as soon as possible but no later than 24 hours after such determination.”102—the OIG
estimated that 47 percent of HRS PRFs were placed within 24 hours of referral to the SPC.103
Based on the current updated requirement that the SPC be responsible for determining placement
of the HRS PRF (without a defined time frame for doing so), the OIG further calculated that the
average time from referral to HRS PRF placement for the patients reviewed was 5 days
(observed range was 0–38 days).
The OIG also noted concerns with the review of HRS PRFs within the required time frame. VA
guidance states that all patients with an HRS PRF should be reevaluated at least every 90 days.104
The OIG estimated that 56 percent of patients with an HRS PRF were reevaluated at least every
90 days.105 Based on the updated requirement that HRS PRFs be reviewed up to 10 days prior to
or after the due date for reevaluation, the OIG found that clinical staff reviewed 26 of 36 patients
within the new time frame (observed range was 14–104 days).106
Additionally, the OIG noted deficiencies with safety plan completion. Per VHA, patients with a
high-risk designation should have a completed suicide safety plan within seven days before or
after the current HRS PRF date.107 The OIG found that safety plans were completed within seven
days for 65 percent of the electronic health records reviewed.108 Completion of safety plans
ensures the patient has a “prioritized written list of coping strategies…to help them lower their
102
VHA DUSHOM Memorandum, High Risk for Suicide Patient Record Flag Changes, October 3, 2017.
103
The OIG estimated that 95 percent of the time, the true compliance rate is between 31.2 and 63.3 percent, which
is statistically significantly below the 90 percent benchmark.
104
VA’s Integrated Approach to Suicide Prevention: Ready Access to Quality Care, Suicide Prevention Coordinator
Guide, January 5, 2018.
105
106
VHA Notice 2020-13.
107
VHA suicide subject matter expert response to timing of safety plan completion, July 8, 2019.
108
VA OIG 20-01276-131 | Page 43 | May 19, 2021

imminent risk of suicidal behavior.”109 A staff psychiatrist stated that the lack of attention to
detail by providers was a reason for noncompliance, noting instances in which providers missed
opportunities to complete the safety plans during appointments.
Recommendation 10
10. The Chief of Staff evaluates and determines any additional reasons for
noncompliance and ensures clinicians complete suicide prevention safety plans in
the expected time frame for patients with High Risk for Suicide Patient Record
Flags.
Target date for completion: October 31, 2021
Medical center response: Clinicians have been educated on the elements and timeframes to
complete a Suicide Safety Plan for Veterans with a High Risk for Suicide Patient Record Flag
(HRS PRF). Compliance with completion of the Suicide Safety Plan will be monitored through
30 retrospective chart reviews for Veterans with an HRS PRF each month. At least 90% of
records reviewed will have a completed Suicide Safety Plan with all required elements for 6
consecutive months. Compliance will be reported at QPS Council.
109
VHA Manual, Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version.
VA OIG 20-01276-131 | Page 44 | May 19, 2021

Care Coordination: Life-Sustaining Treatment Decisions

Life-sustaining treatments (LSTs) are intended to extend the life of a patient expected to die soon
without medical intervention. LSTs may include artificial nutrition, hydration, and mechanical
ventilation. VHA issued the life-sustaining treatment decision (LSTD) handbook to standardize
practices related to discussing and documenting goals of care and LSTDs. Per VHA, the goal is
to encourage personalized, proactive, patient-driven treatment plans for veterans with serious
illness by “eliciting, documenting, and honoring patients’ values, goals, and preferences.”110
VA healthcare facilities were expected to fully implement new procedures outlined in the LSTD
handbook by July 12, 2018.111 Implementation requirements included initiating conversations
about the goals of care. A goals of care conversation is a discussion between a healthcare
provider and a patient or surrogate to help define the patient’s values, goals, and preferences for
care and, based on the discussion, make choices about starting, limiting, or ceasing LSTs.112
VHA requires practitioners to initiate goals of care conversations with high-risk patients—
including hospice patients or their surrogates—within a time frame that meets the medical needs
of the patient or at the time of a triggering event.113
The OIG noted that from July 12, 2018, to June 30, 2019 (the time frame for this retrospective
review), VHA policy defined the elements of a goals of care conversation to be documented in
an LST progress note in the electronic health record, which included
· Decision-making capacity,
· Identification of a surrogate if the patient loses decision-making capacity,
· Patient or surrogate understanding of the patient’s condition,
· Goals of care,
· Plan of care for the use of LST, including whether cardiopulmonary resuscitation will be
attempted in the event of cardiac arrest, and
· Informed consent for the LST plan.
110
VHA Handbook 1004.03, Life-Sustaining Treatment Decisions: Eliciting, Documenting and Honoring Patients’
Values, Goals and Preferences, January 11, 2017, amended to 1004.03(1) on March 19, 2020.
111
VHA Handbook 1004.03(1). The medical facility must fully implement handbook requirements within 18
months of publication.
112
VHA Handbook 1004.03(1). A surrogate is legally authorized under VA policy to serve as the decision maker on
behalf of the patient should the patient lose decision-making capacity.
113
VHA Directive 1139, Palliative Care Consult Teams (PCCT) And VISN Leads, June 14, 2017. Hospice patients
are defined as individuals diagnosed with a terminal condition with a life expectancy of six months or less if the
disease runs its projected course. VHA Handbook 1004.03(1). Triggering events requiring goals of care
conversations include those “prior to referral or following admission (e.g., within 24 hours) to VA or non-VA
hospice.”
VA OIG 20-01276-131 | Page 45 | May 19, 2021

However, on March 19, 2020, VHA amended the requirements related to documenting patients’
goals of care. Although the elements of the goals of care conversation are still required, the LST
progress note must document at a minimum
· Decision-making capacity,
· Goal(s) of care,
· Plan of care for the use of LST, and
· Informed consent for the LST plan.
The OIG is concerned that VHA’s updated requirement could mislead practitioners to only
address those goals of care conversation elements that are required to be documented in the LST
progress note.
The medical center was assessed for its adherence to requirements for goals of care
conversations:
· Completion of LSTD notes
· Timely documentation of LSTD
· Inclusion of required elements in LSTD documentation
· Completion of LSTD note/orders by an authorized provider or delegation to a designee
met all requirements
VHA also requires facilities to appoint a multidisciplinary committee that reviews proposed LST
plans for patients who lack both decision-making ability and a surrogate. The committee must be
composed of three or more diverse disciplines (for example, social workers, nurses, and
physicians) and include one or more members of the facility’s Ethics Consultation Service. 114
Inspectors examined if the medical center established an LSTD committee that was comprised of
a multidisciplinary membership, which included representation from the Ethics Consultation
Service, and reviewed proposed LST plans.
To determine whether the medical center complied with the OIG-selected requirements related to
LSTD for hospice patients, the inspection team reviewed relevant documents and interviewed
key employees. The team also reviewed the electronic health records of 47 hospice patients who
had triggering events from July 12, 2018, through June 30, 2019.
Care Coordination Findings and Recommendations

Generally, the medical center met the above requirements. With VHA’s original requirements
that were in place when these patients received care, the OIG estimated that 56 percent of
114
VHA Handbook 1004.03(1).
VA OIG 20-01276-131 | Page 46 | May 19, 2021

patients’ LST progress notes addressed previous advance directive(s), state-authorized portable
orders, and/or LST notes.115 However, VHA deleted requirements for the documentation of these
elements in the LST progress note.116 The OIG made no recommendations but remains
concerned that this change could result in practitioners not addressing these important goals of
care conversation elements.
115
116
VHA Handbook 1004.03(1).
VA OIG 20-01276-131 | Page 47 | May 19, 2021

Women’s Health: Comprehensive Care

Women represented 9.4 percent of the veteran population as of September 30, 2017. 117
According to data released by the National Center for Veterans Analysis and Statistics in May
2019, the total veteran population and proportion of male veterans are projected to decrease
while the proportion of female veterans are anticipated to increase.118 To help the VA better
understand the needs of the growing women veterans population, efforts have been made by
VHA to identify and address the urgent needs “by examining health care use, preferences, and
the barriers Women Veterans face in access to VA care.”119 Additionally, a VA report in 2016 on
suicide among veterans pointed out concerning trends in suicide among women veterans and
discussed “the importance of understanding suicide risk among women veterans and developing
gender-tailored suicide prevention strategies.”120
VHA requires that all eligible and enrolled women veterans have access to timely, high-quality,
and comprehensive healthcare services in a sensitive and safe environment. Facilities must,
therefore, ensure availability of appropriate resources, services, and staffing ratios.121 VHA also
requires delivery of quality care to all women veterans accessing VA emergency services. In
addition, VHA requires facilities to establish a multidisciplinary women veteran health
committee “that develops and implements a Women’s Health Program strategic plan to guide the
program and assist with carrying out improvements for providing high-quality equitable care for
women Veterans.”122
To determine whether the medical center complied with OIG-selected VHA requirements to
provide comprehensive healthcare services to women veterans, the inspection team reviewed
relevant documents and interviewed selected managers and staff on the following requirements:
· Provision of care requirements
o Designated Women’s Health Patient Aligned Care Team established
o Primary Care Mental Health Integration services available
117
“Veteran Population,” Table 1L: VetPop2016 Living Veterans by Age Group, Gender, 2015–2045, National
Center for Veterans Analysis and Statistics, accessed November 14, 2019,
https://www.va.gov/vetdata/Veteran_Population.asp.
118
“Veteran Population,” National Center for Veterans Analysis and Statistics, accessed September 16, 2019,
https://www.va.gov/vetdata/docs/Demographics/VetPop_Infographic_2019.pdf.
119
Department of Veterans Affairs, Study of Barriers for Women Veterans to VA Health Care, Final Report,
April 2015.
120
Claire Hoffmire, “Concerning Trends in Suicide Among Women Veterans Point to Need for More Research on
Tailored Interventions,” Suicide Prevention, Forum, Spring 2018,
https://www.hsrd.research.va.gov/publications/forum/spring18/default.cfm?ForumMenu=Spring18-5.
121
VHA Directive 1330.01(3), Health Care Services for Women Veterans, February 15, 2017, amended June 29,
2020. (This directive was amended again on January 8, 2021.)
122
VHA Directive 1330.01(3).
VA OIG 20-01276-131 | Page 48 | May 19, 2021

o Gynecologic care coverage available 24/7

o Facility women health primary care providers designated
o CBOC women’s health primary care providers designated
· Oversight of program and monitoring of performance improvement data
o Women Veterans Health Committee established
- Quarterly meetings held
- Core members attend
- Quality assurance data collected and tracked
- Reports made to clinical executive leaders
· Assignment of required staff
o Women Veterans Program Manager
o Women’s Health Medical Director or clinical champion
o Maternity Care Coordinator
o Women’s health clinical liaison at each CBOC
Women’s Health Findings and Recommendations

The medical center complied with requirements for most of the provision of care indicators
reviewed. However, the OIG identified weaknesses with designated CBOC women’s health
primary care providers and the Women Veterans Advisory Committee.123
VHA requires that each CBOC have at least two designated women’s health primary care
providers (WH-PCPs) or that appropriate arrangements are in place for leave coverage in
CBOCs with only one designated WH-PCP.124 The OIG found that three CBOCs did not have at
least two designated WH-PCPs. One CBOC (Georgetown) did not have any designated WH-
PCPs, and two CBOCs (Clermont and Dearborn) had only one designated WH-PCP. When
CBOCs do not have the required number of WH-PCPs or arrangements for leave coverage when
there is only one designated WH-PCP, the medical center’s ability to provide comprehensive
healthcare services to women veterans may be limited. The OIG reviewed the Women Veterans
Advisory Committee minutes for September 2019 and identified that committee members were
123
At the time of the OIG review, the committee was called the Women Veterans Advisory Committee. The medical
center subsequently changed the name to the Women Veterans Health Committee which is reflected in the action
124
VHA Directive 1330.01(2), Health Care Services for Women Veterans, February 15, 2017, amended
July 24, 2018. (This directive was amended on June 29, 2020, and again on January 8, 2021.)
VA OIG 20-01276-131 | Page 49 | May 19, 2021

aware that the medical center did not have the required two WH-PCPs at each CBOC. The Chief
of Primary Care and Chief Nurse Primary Care stated that women’s health training for primary
care providers was scheduled for May 2020; however, it was rescheduled for September 2020,
due to issues caused by the COVID-19 pandemic. The Chief Nurse Primary Care also reported
that primary care providers had left the medical center in 2020 and that there is a provider who
travels to the Georgetown CBOC to conduct gender-specific exams when needed.
Recommendation 11
11. The Chief of Staff evaluates and determines any additional reasons for
noncompliance and ensures that each community-based outpatient clinic has at least
two designated women’s health primary care providers or plans for leave coverage
if there is only one designated provider.125
Medical center response: Two Women’s Health providers have been put in place at each of the
CBOCs except Georgetown. A second provider is being onboarded for Georgetown and likely to
begin approximately June/July 2021. There is one Women’s Health provider currently at the
Georgetown CBOC and there is coverage for that provider during periods of leave. Additionally,
the CBOC Physician Section Chief, who is a Women’s Health provider, is available for
coverage.
VHA requires women veterans health committees to have an active charter, meet quarterly,
report to executive leaders, and have a core membership. That membership must include a
women veterans program manager; a women’s health medical director; “representatives from
primary care, mental health, medical and/or surgical subspecialties, gynecology, pharmacy,
social work and care management, nursing, ED [emergency department], radiology, laboratory,
quality management, business office/Non-VA Medical Care; and a member from executive
leadership.”126 The OIG reviewed the Women Veterans Advisory Committee (this medical
center’s women veterans health committee equivalent) charter and meeting minutes for the four
meetings held between August 1 and December 31, 2019, and found the committee lacked
members from gynecology, social work, and business office/non-VA medical care.
The OIG team also noted that the following members had not attended any meetings:
representatives from medical and/or surgical subspecialties, pharmacy, radiology, and quality
125
The OIG reviewed evidence sufficient to demonstrate that the medical center had completed improvement
actions and therefore closed the recommendation before publication of the report.
VHA Directive 1330.01(2), Health Care Services for Women Veterans, February 15, 2017, amended July 24,
126
2018. (This directive was amended on June 29, 2020, and again on January 8, 2021.)
VA OIG 20-01276-131 | Page 50 | May 19, 2021

management. Lack of expertise and oversight in the review and analysis of data could impact
improvements for quality and equitable women’s health care. Medical center program staff,
including the acting Women’s Health Program Manager, Chief Nurse Primary Care, and acting
Women’s Health Medical Director were unable to provide a reason for noncompliance.
Recommendation 12
12. The Chief of Staff determines the reasons for noncompliance and makes certain that
required members are assigned and consistently attend Women Veterans Advisory
Committee meetings.
Target date for completion: July 31, 2021
Medical center response: The required members have been educated on the importance of
attending or having a representative attend all meetings of the Women Veterans Health
Committee. The Women Veterans Health Committee will demonstrate attendance compliance of
at least 90% for six months. Compliance will be reported at CEB.
VA OIG 20-01276-131 | Page 51 | May 19, 2021

High-Risk Processes: Reusable Medical Equipment

Reusable medical equipment (RME) includes devices or items designed by the manufacturer to
be used for multiple patients after proper decontamination, sterilization, and other processing
between uses. VHA requires that facilities have sterile processing services (SPS) “to ensure
proper reprocessing and maintenance of critical and semi-critical reusable medical
equipment.”127 The goal of SPS is to “provide safe, functional, and sterile instruments and
medical devices and reduce the risk for healthcare-associated infections.”128 To ensure this, VHA
requires facilities to conduct the following activities:
· Maintain a current inventory list of all RME
· Have standard operating procedures (SOPs) that are based on current manufacturers’
guidelines and reviewed at least triennially
· Use CensiTrac® Instrument Tracking System for tracking reprocessed instruments129
· Perform annual risk analysis and report results to the VISN SPS Management Board
· Monitor data for reprocessing and storing RME
· Conduct annual airflow/ventilation system inspections130
VHA requires strict controls that closely monitor climate, storage, and sterilization parameters
and additionally requires that quality assurance documentation of this monitoring be maintained
for a minimum of three years.131 The required documentation includes high-level disinfectant
solution testing, eyewash station maintenance records, and quality assurance records for RME
reprocessing and sterilization.132
In addition, RME reprocessing areas must be clean, restricted, and airflow-controlled. All areas
where RME reprocessing occurs must have safety data sheets, an unobstructed eyewash station,
personal protective equipment available for immediate use, and SOPs readily available to guide
the reprocessing of RME.133
127
VHA Directive 1116(2), Sterile Processing Services (SPS), March 23, 2016.
128
Julie Jefferson, Martha Young. APIC Text of Infection Control and Epidemiology. Association for Professionals
in Infection Control and Epidemiology, 2019. “Chapter 108: Sterile Processing.”
129
VHA DUSHOM Memorandum, Instrument Tracking Systems for Sterile Processing Services, January 1, 2019.
130
131
VHA Directive 1116(2); VHA DUSHOM Memorandum, Interim Guidance for Heating, Ventilation and Air
Conditioning (HVAC) Requirements Related to Reusable Medical Equipment (RME) Reprocessing and Storage,
September 5, 2017.
132
VHA Directive 7704(1), Location, Selection, Installation, Maintenance, and Testing of Emergency Eyewash and
Shower Equipment, February 16, 2016.
133
VA OIG 20-01276-131 | Page 52 | May 19, 2021

VHA also requires facilities to provide training for staff who reprocess RME; this training must
be provided and documented prior to the reprocessing of equipment. The required training
includes mandatory initial competencies, continued annual and essential staff competency
assessments, and monthly continuing education. This ensures that staff have sufficient aptitude,
knowledge, and skills to effectively and safely reprocess and sterilize RME.134
To determine whether the medical center complied with OIG-selected requirements, the
inspection team examined relevant documents and training records and interviewed key
managers and staff on the following:
· Requirements for administrative processes
o RME inventory file is current
o SOPs are based on current manufacturer’s guidelines and reviewed at least
triennially
o CensiTrac® system used
o Risk analysis performed and results reported to the VISN SPS Management
Board
o Airflow checks made
o Eyewash station checked
o Daily cleaning schedule maintained
o Required temperature and humidity maintained
· Monitoring of quality assurance
o High-level disinfectant solution tested
o Bioburden tested
· Completion of staff training, competency, and continuing education
o Required training completed in a timely manner
o Competency assessments performed
o Monthly continuing education received
High-Risk Processes Findings and Recommendations

The medical center met requirements for quality assurance monitoring. However, the OIG
identified deficiencies with required administrative processes and staff training.
134
VA OIG 20-01276-131 | Page 53 | May 19, 2021

VHA requires that facilities “must have standard operating procedures (SOPs) based on
manufacturer’s guidelines that establishes a documented and systematic approach to critical and
semi-critical RME processes.” VHA also requires that “all SOPs are kept up-to-date, reviewed at
least every 3 years and updated when there is a change in process or a change in manufacturer’s
IFU [Instructions For Use].”135 The OIG found that the colonoscope SOP did not contain all the
required steps when compared to the IFU. This may have resulted in inadequate disinfection of
RME. The Chief of SPS and the RME Coordinator cited lack of attention to detail as the reason
for the discrepancies.
Recommendation 13
13. The Associate Director for Patient Care Services evaluates and determines any
additional reasons for noncompliance and makes certain that standard operating
procedures align with manufacturer’s instructions for use.
Medical center response: The standard operating procedure (SOP) for the colonoscope has been
updated to be consistent with all steps of the manufacturer’s instructions for use as required to
adequately disinfect the colonoscope. In addition, the facility has a process in place to review all
SOPs on an ongoing basis to ensure alignment with the manufacturer’s instructions for use. The
SOPs reviewed are documented in the monthly RME committee which reports quarterly to CEB.
For SOPs reviewed they will be in alignment with IFU for 100% compliance over two quarters.
VHA also requires that facilities deploy CensiTrac®, a system for instrument-level tracking.136
The OIG found evidence that while CensiTrac® was operational, the Chief of SPS reported that it
was not yet implemented in one location. The endoscopes stored in the gastrointestinal suite
were tracked through a different program. The use of multiple tracking systems could result in
confusion and potential loss of equipment. The Chief of SPS reported that the VISN purchased
the computers, which are required to fully implement the CensiTrac® system, for installation by
May 31, 2020. However, the goal was not met due to delayed delivery.
Recommendation 14
additional reasons for noncompliance and makes certain that CensiTrac® is fully
operational.
135
136
VHA DUSHOM Memorandum, Instrument Tracking Systems for Sterile Processing Services.
VA OIG 20-01276-131 | Page 54 | May 19, 2021


Target date for completion: May 31, 2021
Medical center response: CensiTrac will be operational in the GI [GastroIntestinal] Lab.
Appropriate technology has been received. Upon completion of set up procedures by OIT [Office
of Information and Technology] and biomedical engineering, staff will be educated on use in the
GI Lab.
According to VHA, facilities must maintain written records of weekly eyewash station function
testing.137 The OIG found that the eyewash stations in the SPS preparation and decontamination
areas were not being tested weekly. This could potentially result in staff injury if the eyewash
station is unavailable in an emergency or not operating properly. The Chief of SPS stated lack of
oversight and attention to detail as reasons for noncompliance.
Recommendation 15
additional reasons for noncompliance and ensures that the Chief of Sterile
Processing Services maintains written records of weekly eyewash station function
testing.
Medical center response: SPS staff will complete required weekly eyewash station testing.
Results will be documented and reported to the Reusable Medical Equipment (RME) Committee
quarterly until there is at least 90% compliance for two consecutive quarters. This will be
reported to CEB quarterly.
Additionally, VHA requires that SPS staff receive monthly continuing education, noting the
Chief of SPS is responsible for “ensuring that all individuals charged with reprocessing duties
are appropriately trained and competency is documented prior to the performance of the assigned
tasks.”138 The Chief of SPS reported that reprocessing occurs in both SPS and the gastrointestinal
suite. The OIG did not find evidence of completed monthly continuing education for 8 of the 10
selected staff during October through December 2019. Of these staff, two assigned to SPS had
some monthly training and the six assigned to the gastrointestinal suite had no monthly training.
Lack of training can create a knowledge gap among staff that results in improperly reprocessed
equipment and compromised patient safety. The Chief of SPS and the RME Coordinator cited
137
138
VA OIG 20-01276-131 | Page 55 | May 19, 2021

lack of oversight and unawareness that the Chief of SPS had to oversee the monthly education of
all staff who reprocess equipment, regardless of location or supervision.
Recommendation 16
additional reasons for noncompliance and ensures that staff who reprocess reusable
medical equipment receive monthly continuing education.
Target date for completion: September 30, 2021
Medical center response: A monthly education schedule has been developed for the fiscal year for
required continuing education. Employee attendance at education sessions will be tracked, and
completion rates reported to the RME committee monthly until 90% completion rate is met for 6
consecutive months.
VA OIG 20-01276-131 | Page 56 | May 19, 2021

Appendix A: Comprehensive Healthcare Inspection

Program Recommendations
The intent is for medical center leaders to use these recommendations as a road map to help
improve operations and clinical care. The recommendations address systems issues as well as
other less-critical findings that, if left unattended, may potentially interfere with the delivery of
quality health care.
Table A.1. Summary Table of Recommendations

Healthcare Requirements Conclusion
Processes
Leadership and · Executive leadership Sixteen OIG recommendations ranging from

Organizational position stability and documentation concerns to noncompliance that can
Risks engagement lead to patient and staff safety issues or adverse
· Employee satisfaction events are attributable to the Director, Chief of Staff,
and ADPCS. See details below.
· Patient experience
· Accreditation surveys and
oversight inspections
· Factors related to
possible lapses in care
and medical center
response
· VHA performance data
(medical center)
· VHA performance data
for CLCs
COVID-19 · Emergency preparedness The results of the OIG’s evaluation of the medical
Readiness and · Supplies, equipment, and center’s COVID-19 pandemic readiness and
Response infrastructure response were compiled and reported with other
facilities in a separate publication to provide
· Staffing stakeholders with a more comprehensive picture of
· Access to care regional VHA challenges and ongoing efforts.
· CLC patient care and
operations
· Staff feedback
VA OIG 20-01276-131 | Page 57 | May 19, 2021

Healthcare Requirements Critical Recommendations for

Processes Recommendations for Improvement
Improvement
Quality, Safety, · QSV Committee · The QSV · None
and Value · Protected peer reviews Committee fully
implements and
· UM reviews monitors
· Patient safety improvement
actions.
· All applicable
deaths are peer
reviewed.
· Root cause
analyses include all
required elements.
Medical Staff · FPPEs · Clinical managers · Clinical Executive
Privileging · OPPEs define in advance, Board meeting
communicate, and minutes consistently
· Provider exit reviews and document criteria reflect the review of
reporting to state licensing for FPPE in professional practice
boards practitioner profiles. evaluation results in
· Service chiefs the decision to
document the recommend initiation
results of FPPEs in and continuation of
practitioner profiles. privileges.
· Service chiefs · Provider exit review
collect service- forms are completed
specific OPPE within seven
data. business days of
licensed healthcare
· Service chiefs professionals’
recommend departure from the
continuation of medical center.
privileges based
upon OPPE data.
Medication · Provision of pain · None · None
Management: management using long-
Long-Term term opioid therapy
Opioid Therapy · Program oversight and
evaluation
Mental Health: · Designated facility suicide · Clinicians complete · None
Suicide prevention coordinator suicide prevention
Prevention · Tracking and follow-up of safety plans within
Program high-risk veterans the expected time
frame for patients
· Provision of suicide with High Risk for
prevention care Suicide Patient
· Completion of suicide Record Flags.
prevention training
requirements
VA OIG 20-01276-131 | Page 58 | May 19, 2021

Healthcare Requirements Critical Recommendations for

Processes Recommendations for Improvement
Improvement
Care · LSTD multidisciplinary · None · None
Coordination: committee
Life-Sustaining · Goals of care
Treatment conversation
Decisions documentation
· LSTD note/orders
completed by an
authorized provider or
delegated appropriately
Women’s · Provision of care · Each CBOC has at · Required members
Health: · Program oversight and least two are assigned and
Comprehensive performance improvement designated consistently attend
Care data monitoring women’s health Women Veterans
primary care Advisory Committee
· Staffing requirements providers or plans meetings.
for leave coverage
plans if there is
only one
designated
provider.
High-Risk · Administrative processes · Standard operating · CensiTrac® is fully
Processes: · Quality assurance procedures align operational.
Reusable with manufacturer’s · Chief of SPS
Medical · Staff training instructions for use. maintains written
Equipment records of weekly
eyewash station
function testing.
· Staff who reprocess
RME receive monthly
continuing education.
VA OIG 20-01276-131 | Page 59 | May 19, 2021

Appendix B: Medical Center Profile

The table below provides general background information for this high complexity (1b) affiliated
medical center reporting to VISN 10.1
Table B.1. Profile for Cincinnati VA Medical Center (539)

Profile Element Medical Center Medical Center Medical Center
Data Data Data
FY 2017* FY 2018 FY 2019‡
Total medical care budget $435,616,990 $453,284,014 $477,527,792
Number of:
· Unique patients 42,100 42,306 42,377
· Outpatient visits 583,495 600,491 605,704
· Unique employees 2,045 2,035 2,092
Type and number of operating beds:
· Community living center 64 64 64
· Domiciliary 107 107 107
· Medicine 62 62 62
· Mental health 24 23 23
· Neurology 2 2 2
· Surgery 29 29 29
Average daily census:
· Community living center 44 46 46
· Domiciliary 86 88 85
· Medicine 43 42 43
· Mental health 15 15 15
· Neurology 2 1 1
1
Associated with a medical residency program. The VHA medical centers are classified according to a facility
complexity model; a designation of “1b” indicates a facility with “medium-high volume, high risk patients, many
complex clinical programs, and medium-large research and teaching programs.”
VA OIG 20-01276-131 | Page 60 | May 19, 2021

Profile Element Medical Center Medical Center Medical Center

Data Data Data
FY 2017* FY 2018 FY 2019‡
· Surgery 9 7 7
Source: VA Office of Academic Affiliations, VHA Support Service Center, and VA Corporate Data Warehouse.
*October 1, 2016, through September 30, 2017.
October 1, 2017, through September 30, 2018.
‡
October 1, 2018, through September 30, 2019.
VA OIG 20-01276-131 | Page 61 | May 19, 2021

Appendix C: VA Outpatient Clinic Profiles

The VA outpatient clinics in communities within the catchment area of the medical center provide primary care integrated with
women’s health, mental health, and telehealth services. Some also provide specialty care, diagnostic, and ancillary services. Table C.1.
provides information relative to each of the clinics.1
Table C.1. VA Outpatient Clinic Workload/Encounters and

Specialty Care, Diagnostic, and Ancillary Services Provided
Location Station Primary Care Mental Health Specialty Care Diagnostic Ancillary
No. Workload/ Workload/ Services Provided Services Services
Encounters Encounters Provided Provided
Bellevue, KY 539GA 5,906 3,339 Anesthesia EKG Nutrition
Dermatology Pharmacy
Social work
Weight
management
Cincinnati, OH 539GB 10,931 6,844 Anesthesia EKG Nutrition
Eye Social work
Infectious disease Weight
Podiatry management
Rehab physician
1
VHA Directive 1230(3), Outpatient Scheduling Processes and Procedures, July 15, 2016, amended January 7, 2021. An encounter is a “professional contact
between a patient and a provider vested with responsibility for diagnosing, evaluating, and treating the patient’s condition.” Specialty care services refer to non-
primary care and non-mental health services provided by a physician. Diagnostic services include electrocardiogram (EKG). Ancillary services include nutrition,
pharmacy, social work, and weight management.
VA OIG 20-01276-131 | Page 62 | May 19, 2021

Location Station Primary Care Mental Health Specialty Care Diagnostic Ancillary
No. Workload/ Workload/ Services Provided Services Services
Encounters Encounters Provided Provided
Greendale (Dearborn), IN 539GC 6,420 3,255 Anesthesia EKG Nutrition
Eye Social work
Podiatry Weight
management
Florence, KY 539GD 8,532 3,349 Dermatology EKG Nutrition
Eye Pharmacy
Podiatry Social work
Weight
management
Hamilton, OH 539GE 7,473 4,380 Anesthesia EKG Pharmacy
Dermatology Nutrition
Eye Social work
Podiatry Weight
Pulmonary/ management
Respiratory disease
Georgetown, OH 539GF 3,639 825 Anesthesia EKG Nutrition
Eye
Podiatry
Cincinnati, OH 539QC 1 – – – –
Cincinnati, OH 539QD – 711 Endocrinology – Nutrition
Poly-Trauma Weight
management
Source: VHA Support Service Center and VA Corporate Data Warehouse.
VA OIG 20-01276-131 | Page 63 | May 19, 2021

Appendix D: Patient Aligned Care Team Compass Metrics

Quarterly New PC Patient Average Wait Time in Days
Number of Days
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
(539GB) (539GF)
(539) (539GA) (539GC) (539GD) (539GE) (539QC) Vine
VHA Total Clermont Georgetown,
Cincinnati, OH Bellevue, KY Dearborn, IN Florence, KY Hamilton, OH Street, OH
County, OH OH
JUL-FY19 7.3 3.6 7.2 5.3 1.0 7.0 7.1 12.4 n/a
AUG-FY19 7.4 4.2 4.5 4.4 1.8 3.1 2.4 12.1 n/a
SEP-FY19 7.3 2.1 24.5 3.2 2.4 3.7 2.9 4.6 n/a
OCT-FY20 6.9 4.0 4.3 2.4 3.5 7.0 5.8 1.6 0.0
NOV-FY20 7.1 2.5 31.8 2.1 4.0 3.1 7.3 3.5 7.0
DEC-FY20 7.8 3.4 4.3 1.3 3.2 2.5 4.5 4.1 0.0
JAN-FY20 8.3 3.7 5.7 1.9 4.6 5.6 5.5 3.5 0.0
FEB-FY20 8.1 3.0 5.3 2.9 1.5 4.8 5.4 3.8 0.0
MAR-FY20 6.9 2.7 2.1 3.7 3.6 4.8 6.0 5.0 0.0
APR-FY20 3.6 2.6 0.6 0.0 n/a 5.7 1.8 0.7 n/a
MAY-FY20 4.0 2.2 1.5 2.3 3.5 4.3 7.6 0.3 0.0
JUN-FY20 4.9 2.4 11.2 77.0 0.0 8.4 9.7 5.4 0.0
Source: VHA Support Service Center. Department of Veterans Affairs, Patient Aligned Care Teams Compass Data Definitions, https://vssc.med.va.gov,
accessed October 21, 2019.
Note: The OIG did not assess VA’s data for accuracy or completeness. The OIG omitted (539A4) Fort Thomas, KY and (539QB) Cincinnati, OH as no data
were reported. The OIG has on file the medical center’s explanation for the increased wait times for the Clermont County, OH CBOC.
Data Definition: “The average number of calendar days between a New Patient’s Primary Care completed appointment (clinic stops 322, 323, and 350,
excluding [Compensation and Pension] appointments) and the earliest of [three] possible preferred (desired) dates (Electronic Wait List (EWL)), Cancelled
by Clinic Appointment, Completed Appointment) from the completed appointment date.” Prior to FY 2015, this metric was calculated using the earliest
possible create date. The absence of reported data is indicated by “n/a.”
VA OIG 20-01276-131 | Page 64 | May 19, 2021

Quarterly Established PC Patient Average Wait Time in

10.0
Days
9.0
Number of Days
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
(539GB) (539GF)
(539) (539GA) (539GC) (539GD) (539GE) (539QC) Vine
VHA Total Clermont Georgetown,
Cincinnati, OH Bellevue, KY Dearborn, IN Florence, KY Hamilton, OH Street, OH
County, OH OH
JUL-FY19 4.6 4.6 6.4 3.5 1.5 4.4 6.3 6.9 n/a
AUG-FY19 4.5 4.3 2.6 3.3 2.5 2.5 2.4 6.9 n/a
SEP-FY19 4.3 2.2 7.8 2.6 1.6 1.6 1.5 5.5 n/a
OCT-FY20 3.9 2.2 5.3 2.0 1.4 3.2 2.2 2.8 0.0
NOV-FY20 4.2 2.4 3.5 1.9 2.4 2.9 2.6 3.5 0.0
DEC-FY20 4.2 2.4 5.0 2.4 1.5 2.5 3.3 4.0 0.0
JAN-FY20 4.8 3.1 2.9 2.3 2.5 4.1 7.2 3.9 0.5
FEB-FY20 4.3 2.4 3.8 1.8 1.2 2.5 5.7 2.7 1.4
MAR-FY20 3.9 2.4 2.8 1.8 1.8 2.0 3.1 3.2 0.0
APR-FY20 1.9 1.8 0.1 0.6 2.2 0.1 2.3 0.2 n/a
MAY-FY20 2.1 2.3 8.8 1.8 0.7 5.9 4.6 2.0 n/a
JUN-FY20 3.7 3.3 8.9 4.6 0.3 2.9 1.7 6.1 n/a
Source: VHA Support Service Center. Department of Veterans Affairs, Patient Aligned Care Teams Compass Data Definitions, https://vssc.med.va.gov,
accessed October 21, 2019.
Note: The OIG did not assess VA’s data for accuracy or completeness. The OIG omitted (539A4) Fort Thomas, KY and (539QB) Cincinnati, OH) as no data
were reported.
Data Definition: “The average number of calendar days between an Established Patient’s Primary Care completed appointment (clinic stops 322, 323, and
350, excluding [Compensation and Pension] appointments) and the earliest of [three] possible preferred (desired) dates (Electronic Wait List (EWL),
Cancelled by Clinic Appointment, Completed Appointment) from the completed appointment date.”
VA OIG 20-01276-131 | Page 65 | May 19, 2021

Appendix E: Strategic Analytics for Improvement

and Learning (SAIL) Metric Definitions
Measure Definition Desired Direction
Adjusted LOS Acute care risk adjusted length of stay A lower value is better than a higher value
Composite measure based on three individual All Employee Survey data use
AES Data Use A higher value is better than a lower value
and sharing questions
Care transition Care transition (inpatient) A higher value is better than a lower value
Centers for Medicare and Medicaid Services (CMS) risk standardized mortality
CMS MORT A lower value is better than a higher value
rate
ED Throughput Composite measure for timeliness of care in the emergency department A lower value is better than a higher value
HC assoc infections Health care associated infections A lower value is better than a higher value
Healthcare Effectiveness Data and Information Set (HEDIS) composite score

HEDIS like – HED90_1 related to outpatient behavioral health screening, prevention, immunization, A higher value is better than a lower value
and tobacco
HEDIS composite score related to outpatient care for diabetes and ischemic
HEDIS like – HED90_ec A higher value is better than a lower value
heart disease
MH continuity care Mental health continuity of care (FY14Q3 and later) A higher value is better than a lower value
MH exp of care Mental health experience of care (FY14Q3 and later) A higher value is better than a lower value
MH popu coverage Mental health population coverage (FY14Q3 and later) A higher value is better than a lower value
Oryx – GM90_1 ORYX inpatient composite of global measures A higher value is better than a lower value
VA OIG 20-01276-131 | Page 66 | May 19, 2021

Measure Definition Desired Direction
PCMH care coordination PCMH care coordination A higher value is better than a lower value
PCMH same day appt Days waited for appointment when needed care right away (PCMH) A higher value is better than a lower value
PCMH survey access Timely appointment, care and information (PCMH) A higher value is better than a lower value
PSI90 Patient Safety and Adverse Events Composite (PSI90) focused on potentially A lower value is better than a higher value
avoidable complications and events
Rating hospital Overall rating of hospital stay (inpatient only) A higher value is better than a lower value
Rating PC provider Rating of PC providers (PCMH) A higher value is better than a lower value
Rating SC provider Rating of specialty care providers (specialty care) A higher value is better than a lower value
RSRR-HWR Hospital wide readmission A lower value is better than a higher value
SC care coordination SC (specialty care) care coordination A higher value is better than a lower value
SC survey access Timely appointment, care and information (specialty care) A higher value is better than a lower value
SMR30 Acute care 30-day standardized mortality ratio A lower value is better than a higher value
Stress discussed Stress discussed (PCMH Q40) A higher value is better than a lower value
VA OIG 20-01276-131 | Page 67 | May 19, 2021

Appendix F: Community Living Center (CLC) Strategic Analytics for

Improvement and Learning (SAIL) Measure Definitions
Measure Definition
Ability to move independently worsened (LS) Long-stay measure: percentage of residents whose ability to move independently worsened.
Catheter in bladder (LS) Long-stay measure: percent of residents who have/had a catheter inserted and left in their bladder.
Discharged to Community (SS) Short-stay measure: percentage of short-stay residents who were successfully discharged to the
community.
Falls with major injury (LS) Long-stay measure: percent of residents experiencing one or more falls with major injury.
Help with ADL (LS) Long-stay measure: percent of residents whose need for help with activities of daily living has
increased.
High risk PU (LS) Long-stay measure: percent of high-risk residents with pressure ulcers.
Improvement in function (SS) Short-stay measure: percentage of residents whose physical function improves from admission to
discharge.
Moderate-severe pain (LS) Long-stay measure: percent of residents who self-report moderate to severe pain.
Moderate-severe pain (SS) Short-stay measure: percent of residents who self-report moderate to severe pain.
New or worse PU (SS) Short-stay measure: percent of residents with pressure ulcers that are new or worsened.
Newly received antipsych meds (SS) Short-stay measure: percent of residents who newly received an antipsychotic medication.
Outpatient ED visit (SS) Short-stay measure: percent of short-stay residents who have had an outpatient emergency
department (ED) visit.
Physical restraints (LS) Long-stay measure: percent of residents who were physically restrained.
VA OIG 20-01276-131 | Page 68 | May 19, 2021

Measure Definition
Receive antipsych meds (LS) Long-stay measure: percent of residents who received an antipsychotic medication.
Rehospitalized after NH Admission (SS) Short-stay measure: percent of residents who were re-hospitalized after a nursing home admission.
UTI (LS) Long-stay measure: percent of residents with a urinary tract infection.
VA OIG 20-01276-131 | Page 69 | May 19, 2021

Appendix G: VISN Director Comments

Department of Veterans Affairs Memorandum
Date: April 6, 2021
From: Network Director, VA Healthcare System Serving Ohio, Indiana and Michigan
(10N10)
Subj: Comprehensive Healthcare Inspection of the Cincinnati VA Medical Center in
Ohio
To: Director, Office of Healthcare Inspections (54CH03)
Director, GAO/OIG Accountability Liaison (VHA 10B GOAL Action)
1. I have reviewed and concur with the response for the draft report of our
Comprehensive Healthcare Inspection of the Cincinnati VA Medical Center in
Ohio.
2. I concur with the responses and action plans submitted by the Cincinnati VA
Medical Center Interim Director.
3. Thank you for the opportunity to respond to this report.
(Original signed by:)

RimaAnn O. Nelson
VA OIG 20-01276-131 | Page 70 | May 19, 2021

Appendix H: Interim Medical Center Director

Comments
Department of Veterans Affairs Memorandum
Date: April 5, 2021
From: Interim Director, Cincinnati VA Medical Center (539/00)
Subj: Comprehensive Healthcare Inspection of the Cincinnati VA Medical Center in
Ohio
To: Director, VA Healthcare System Serving Ohio, Indiana and Michigan (10N10)
Thank you for your thorough review. Please find the Medical Center's attached
response to the draft Comprehensive Healthcare Inspection of the Cincinnati VA
Medical Center in Ohio. I concur with the finding, recommendations and action
plans.
(Original signed by:)

Thelma J. Johnson
VA OIG 20-01276-131 | Page 71 | May 19, 2021

OIG Contact and Staff Acknowledgments

Contact For more information about this report, please contact the
Office of Inspector General at (202) 461-4720.
Inspection Team Tasha Felton-Williams, DNP, ACNP, Team Leader

Donna Murray, MSN, RN, Co-Team Leader
Rachel Agbi, DBA, MSN
Melinda Alegria, AUD, CCC-A
Patricia Calvin, MBA, RN
Kristie Van Gaalen, BSN, RN
Michelle Wilt, MBA, BSN
Other Contributors Elizabeth Bullock

Shirley Carlile, BA
Alicia Castillo-Flores, MBA, MPH
Limin Clegg, PhD
Kaitlyn Delgadillo, BSPH
Ashley Fahle Gonzalez, BS, MPH
Jennifer Frisch, MSN, RN
Justin Hanlon, BS
LaFonda Henry, MSN, RN-BC
Susan Lott, MSA, RN
Scott McGrath, BS
Larry Ross, Jr., MS
Krista Stephenson, MSN, RN
Robyn Stober, JD, MBA
Caitlin Sweany-Mendez, MPH, BS
Robert Wallace, ScD, MPH
VA OIG 20-01276-131 | Page 72 | May 19, 2021

Report Distribution
VA Distribution
Office of the Secretary
Veterans Benefits Administration
Veterans Health Administration
National Cemetery Administration
Assistant Secretaries
Office of General Counsel
Office of Acquisition, Logistics, and Construction
Board of Veterans’ Appeals
Director, VISN 10: VA Healthcare System
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 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:
Indiana – Mike Braun, Todd Young
Kentucky – Mitch McConnell, Rand Paul
Ohio – Sherrod Brown, Rob Portman
U.S. House of Representatives:
Indiana – Greg Pence
Kentucky – Thomas Massie
Ohio – Steve Chabot, Warren Davidson, Mike Turner, Brad Wenstrup
OIG reports are available at www.va.gov/oig.
VA OIG 20-01276-131 | Page 73 | May 19, 2021

VA OIG Report On Cincinnati VA

Uploaded by

Copyright:

Available Formats

VA OIG Report On Cincinnati VA

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

VA OIG Report On Cincinnati VA

Uploaded by

Copyright:

Available Formats

Office of Healthcare Inspections

VETERANS HEALTH ADMINISTRATION

CHIP REPORT REPORT #20-01276-131 MAY 19, 2021

In addition to general privacy laws that govern release of medical

Report suspected wrongdoing in VA programs and operations

VA OIG 20-01276-131 | Page i | May 19, 2021

VA OIG 20-01276-131 | Page ii | May 19, 2021

VA OIG 20-01276-131 | Page iii | May 19, 2021

Leadership and Organizational Risks

VA OIG 20-01276-131 | Page iv | May 19, 2021

COVID-19 Pandemic Readiness and Response

Quality, Safety, and Value

VA OIG 20-01276-131 | Page v | May 19, 2021

Medical Staff Privileging

VA OIG 20-01276-131 | Page vi | May 19, 2021

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

VA OIG 20-01276-131 | Page vii | May 19, 2021

Report Overview ............................................................................................................................ iii

Inspection Results ..................................................................................................................... iv

Purpose and Scope ...........................................................................................................................1

Results and Recommendations ........................................................................................................5

Leadership and Organizational Risks..........................................................................................5

COVID-19 Pandemic Readiness and Response ........................................................................22

Quality, Safety, and Value ........................................................................................................23

Medical Staff Privileging ..........................................................................................................29

VA OIG 20-01276-131 | Page viii | May 19, 2021

Medication Management: Long-Term Opioid Therapy for Pain ..............................................37

Mental Health: Suicide Prevention Program.............................................................................40

Care Coordination: Life-Sustaining Treatment Decisions ........................................................45

Women’s Health: Comprehensive Care ....................................................................................48

High-Risk Processes: Reusable Medical Equipment ................................................................52

Appendix A: Comprehensive Healthcare Inspection Program Recommendations .......................57

Appendix B: Medical Center Profile .............................................................................................60

Appendix C: VA Outpatient Clinic Profiles ..................................................................................62

Appendix D: Patient Aligned Care Team Compass Metrics .........................................................64

VA OIG 20-01276-131 | Page ix | May 19, 2021

Appendix G: VISN Director Comments ........................................................................................70

Appendix H: Interim Medical Center Director Comments............................................................71

OIG Contact and Staff Acknowledgments ....................................................................................72

Report Distribution ........................................................................................................................73

VA OIG 20-01276-131 | Page x | May 19, 2021

Purpose and Scope

VA OIG 20-01276-131 | Page 1 | May 19, 2021

5. Medication management (targeting long-term opioid therapy for pain)

VA OIG 20-01276-131 | Page 2 | May 19, 2021

VA OIG 20-01276-131 | Page 3 | May 19, 2021

VA OIG 20-01276-131 | Page 4 | May 19, 2021

Results and Recommendations

Executive Leadership Position Stability and Engagement

VA OIG 20-01276-131 | Page 5 | May 19, 2021

Medical Center Director

Chief of Staff ADPCS Associate Director

Chaplain Community Living Center Engineering Quality & Clinical Informatics

Figure 3. Medical center organizational chart.

Table 1. Executive Leader Assignments

VA OIG 20-01276-131 | Page 6 | May 19, 2021

VA OIG 20-01276-131 | Page 7 | May 19, 2021

Medical Center Director