Inspection Summary: Assess Keller Army Community Hospital …graphics8.nytimes.com/packages/pdf/national/military... · 2018-01-31 · DEPARTMENT OF THE ARMY THE INSPECTOR GENERAL

Department of the Army Inspector General (DAIG) Report No. ID-1406 19 August 2014

Inspection Summary: Assess Keller Army Community Hospital (KACH)

compliance with Army and DoD policy· and adherence to The Joint Commission standards.

What We Did: The DAIG conducted a Special Interest Item (Sil) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission (T JC) standards.

What We Found: • KACH Medical Activity (MEDDAC) Regulation 15-1 committees are not functioning IAW AR 40-68. • Employee Competency Assessment Files (CAF) are not up to date. • Work stopped on MILCON Project #59220 (KACH Expansion) is significantly impacting hospital

operations and morale (work will resume o/a SEP 14). • The CPAC servicing West Point is inadequately manned to support client needs in compliance with

Office of Personnel Management (OPM) timelines and as a result is outsourcing all actions supporting USMNKACH.

--MEDCOM reimbursable positions are not being used by CPAC servicing West Point exclusively to support KACH requirements for recruiting, classification, management I employee relations, and training. --The CPAC servicing West Point, Northeast Region CHRA, and CHRA headquarters fail to apply adequate quality control and oversight of personnel actions, resulting in one regulatory and numerous procedural findings.

• KACH Command Climate Survey data is concerning due to its indicators of significant dissatisfaction among hospital employees.

What We Recommend: • Commander US Army Medical Command (MEDCOM): • Develop and publish a policy to standardize minimum requirements and establish inspectable

items for all MEDDAC Regulations 15-1. • Direct Regional Medical Centers (RMC) to provide a T JC mock survey 18 months before the

MTFs' next T JC survey, establish minimum requirements for RMCs to review MEDDAC CAFs, and ensure RMCs conduct inspections to include a review of the results of subordinate commanders' command climate surveys IAW ARs 600-20 and 1-201.

• Explore options to avoid simultaneous turnover of hospital command teams, and consider the addition of a civilian executive officer position for hospitals under MEDCOM to provide civilian leadership and continuity.

• Director, Civilian Human Resources Agency (CHRA): • Review staffing and ensure West Point CPAC is adequately manned and explore standing up a

virtual office to support KACH from another geographic location. • Ensure that all trainees receive appropriate training and oversight and ensure compliance with

CHRA policies and procedures through appropriate oversight and quality review. • ICW all reimbursable partners (to include MEDCOM), ensure that positions are fully funded and

fully compliant with support agreements.

For Official us/ Only {FOUO)

SAIG-ZA Table of Contents to Memorandum, Special Interest Item (Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards.

· Table of Contents

Document

Cover Letter Enclosure 1: Verification Matrix Enclosure 2: Objective 1 - Policy & Training

Tab A (Financial Audit Feedback) Enclosure 3: Objective 2 - Infrastructure & Sanitation

TAB A- (MRR Timeline) Enclosure 4: Objective 3 - Hiring policies, practice and procedures Enclosure 5: Objective 4 - Command climate

TAB A- (Employee Survey Feedback) Enclosure 6: Inspection Methodology Enclosure 7: Detailed Inspection Plan Enclosure 8: Appendix 1 (Directive) Enclosure 9: Appendix 2 (Senior Brief) Enclosure 10: Appendix 3 (Detailed References) Enclosure 11 : Appendix 4 (Acronyms) Enclosure 12: Appendix 5 (Stakeholder Brief)

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-DEPARTMENT OF THE ARMY

THE INSPECTOR GENERAL 1700 ARMY PENTAGON

WASHINGTON DC 20310-1700

SAIG-ZA

MEMORANDUM FOR SECRETARY OF THE ARMY

SUBJECT: Special Interest Item (Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and Department of Defense (DoD) policy and guidance and The Joint Commission (T JC) standards

1. Purpose. From 9 July - 8 August 2014, the Department of the Army Inspector General (DAIG) conducted a compressed Special Interest Item (Sil) Inspection of Keller Army Community Hospital (KACH), West Point, New York to assess compliance with and implementation of applicable Army and DoD policy and guidance and the Joint Commission standards. This memorandum provides an executive summary of the inspection results .

2. Background. Based on an anonymous letter received on 16 June 2014, the Secretary of the Army directed the DAIG to conduct a systemic inspection that addressed 25 specific issues that fall into nine general categories: training , ethical concerns , hospital operations, hospital infrastructure, hospital sanitation , hiring actions, budgetary constraints, patient care and patient records.

3. Inspection Objectives. The objectives of the inspection:

a. Assess the adequacy of KACH policy and training with regard to (WRT) hospital operations.

b. Assess the adequacy of KACH infrastructure and sanitation.

c. Assess hiring policies, practices and procedures for KACH IAW applicable regulatory guidance.

d. Assess the command climate of KACH IAW applicable regulatory guidance.

4. Inspection Methodology. A nine-person DAIG inspection team, accompanied by seven subject matter experts (SME) from the Deputy Chief of Staff, G1 ; Civilian Human Resources Agency (DCS-G1, CHRA); Office of The Surgeon General and US Army Medical Command (OTSG I MEDCOM); US Army Corps of Engineers (USACE); and US Army Audit Agency (AAA) conducted an eight day (compressed) Sii inspection at KACH focusing on compliance and implementation of ~II applicable guidance. The inspection based its findings and observations on information gathered through detailed

SAIG-ZA SUBJECT: Special Interest Item (Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and Department of Defense (DoD) policy and guidance and The Joint Commission (T JC) standards

research, comprehensive document reviews, multiple sensing sessions, and on interviews with hospital leaders, staff, Soldiers, Department of the Army Civilians (DAC), and Family Members associated with KACH. The inspection team conducted a comprehensive assessment of the policies, procedures, and oversight mechanisms supporting the hospital.

5. Inspection Summary. The inspection team assessed KACH across four objectives and developed several themes, concerns, and focus areas. While the team did find some validity in select complaints from within the letter, they identified no risk to patient safety at KACH. In fact, we did find that KACH is staffed with dedicated professionals who enjoy patient care. In addition, the new command team, in place since 11 July 2014, is already making a positive impact. The hospital also receives adequate funding and rates number one of all U.S. Army Medical Activities (MEDDAC) for patient satisfaction:

Despite the positive indicators above, KACH does have its share of challenges. Worker, (vice beneficiary), satisfaction, seems to be a key concern. One common factor resonating across the workforce is the stalled Military Construction (MILCON) project. This project, initiated in October 2011, was designed to address many of the hospital's workspace and mechanical challenges. The impact of the project's delay goes beyond the immediate physical issues and has given rise to a significant amount of angst and rumors concerning the very future of KACH. Command climate surveys surfaced many concerns outlined in the letter; these concerns referred largely to the previous two command teams and not to the current one.

Since 2007, the hospital has experienced a near-simultaneous turnover of the commander, Command Sergeant Major, Deputy Commander for Clinical Services (DCCS), Deputy Commander for Nursing (DCN) and Deputy Commander for Administration (OCA) at virtually the same time every two years. This practice exacerbates an already tenuous command climate. Additionally, an under-resourced Civilian Personnel Advisory Center (CPAC), poor communications, and unusually lengthy hlring actions complicate hiring practices. Lastly, the hospital committees required by KACH MEDDAC Regulation {Reg) 15-1 are not fully functional which could impact credentialing at the next T JC Survey.

6. Summary of Findings

a. Hospital Policy and Training. The cornerstone of Army hospital management and administration is founded on departmental and inter-departmental committee activity. KACH's MEDOAC Reg 15-1, paragraphs 5 and 6, requires the Medical

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SAIG-ZA SUBJECT: Special Interest Item (Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and Department of Defense (DoD) policy and guidance and The Joint Commission (T JC) standards .

Treatment Facility (MTF) to hold 25 committee meetings on a regular basis and to maintain meeting minutes and tracking logs. Through discussions and review of committee minutes, the inspection team found that a·significant number of feeder committees were not meeting as required by KACH MEDDAC Reg 15-1 (monthty I quarterly) nor were they providing feedback to the five mandatory executive committees as required by AR 40-68. Also, attendance by committee members was lacking and a review of committee minutes showed an insufficient level of detail to properly track committee activities. Further, information flow up and down the committee structure was not always evident. The MTF staff reported during discussions and interviews that there is no formal process in place to staff policy or procedural changes.

KACH is one of 34 or more MEDDACs that follow their own version of this regulation. There is similarity but no standardization across MEDCOM for activities or hospitals. This lack of consistency has an impact well beyond the immediate issue of KACH - it impacts MEDCOM as a whole.

KACH currently has no policy or standard operating procedures (SOP) in place regarding submission of a Patient Safety Report (PSR). MEDCOM has directed that PSRs be completed to report safety events from near-misses to significant bodily harm. Generally, KACH members complete PSRs only when an adverse event occurs, but not for close calls. The intent of submitting a PSR is for the committee to meet and review each PSR and discuss the event and outcome. Providing feedback promotes an adaptive and learning environment. The Patient Safety committee meeting minutes lacked sufficient detail to effectively track PSRs, committee activities, or outcomes of the events. Enforcement and oversight was also lacking within KACH, the Regional Medical Command (RMC), and the MEDCOM headquarters.

There are a number of deficiencies in the Competency Assessment Files (CAF) that, if left uncorrected, could jeopardize credentialing at KACH during the next T JC Survey. CAFs document individual level of competence and how well those individuals perform their duties. The team reviewed 20 CAF packets during the inspection and found training and documentation discrepancies in all. Common problems included a lack of certification validation such as Basic Life Support, Advanced Cardiovascular Life Support and licensure. Documentation gaps consisted of missing competency assessments and formal work area orientations required per AR 40-68 (paragraphs 5-1/8-1) and Appendix R of KACH's MEDDAC Regulation 1-200. Folders reviewed were not current and did not appear to have been updated since the last T JC Survey in 2012. AR 40-68, Appendix C, requires annual reviews and updates.

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SAIG-ZA SUBJECT: Special Interest Item (Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and Department of Defense (DoD) policy and guidance and The Joint Commission (T JC) standards .

b. KACH Infrastructure and Sanitation. The KACH structure dates back to 1977 and requires major repair and updates. As a structure, it is well suited for inpatient operations b~t offers limited adaptability for current outpatient treatment requirements. For years, KACH (as real property) fell under management of the U.S. Army Installation Management Command (IMCOM) and its predecessors, with sustainment consuming the majority of available resources. In 2010, KACH ownership and management migrated to MEDCOM, which focused on long range planning to meet the hospital's future medical needs of 21st century. Today, the facility lacks sufficient outpatient clinic capabilities and administrative space, and requires considerable replacement of major infrastructure components. For example, six major clinics lack adequate space to properly conduct patient care, and KACH's expansion MILCON project consumed much of the hospital's existing parking capacity.

Completing infrastructure repairs without extended closure of major hospital functions was impossible. MEDCOM, Health Facility Planning Agency and US Army Corps of . Engineers (USACE) determined that a series of sequentially conducted, phased repairs and upgrades best supported all needs. The first hurdle would be MILCON Project #59220 which was designed to add about 51,000 square feet to KACH, allowing relocation of outpatient clinics and administrative space to a new wing. In tum, the vacated space would be renovated I modernized, addressing heating, ventilation and ·plumbing problems that plagued the facility. Sustainment, renewal, and maintenance (SRM) projects and phased Major Repair and Renewal (MRR) projects are approved for 2014 - 2015. However, default by the prime contractor delayed the MILCON project for nearly a year. With the project 63% complete, it was challenging for KACH to find another prime contractor willing to assume responsibility for the structure and the work previously accomplished. This construction project delay was never explained to an already frustrated and ill-informed hospital staff. The good news is that, as of 15 August 2014, MILCON # 59220 was awarded to a new prime contractor and construction will begin again in September 2014.

c. Hiring Policies, Practices and Procedures. KACH's support received from the CPAC servicing West Point is inadequate to support KACH's human resources (HR) needs. Currently MEDCOM provides additional support to CHRA by funding four CHRA West Point CPAC reimbursable positions; however these positions are not servicing KACH as required. The Director, CPAC servicing West Point, North East (NE) Region CHRA and CHRA Headquarters (CHRA-HQ) are failing to apply the proper quality control and oversight of personnel actions resulting in one regulatory violation and numerous procedural findings. Numerous KACH employees perform dual or triple-hatted functions that are not reflected in the individual's position description (PD). This situation violates employment policy in that it represents an improper accretion of

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SAIG-ZA SUBJECT: Special Interest Item (Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and Department of Defense (DoD) policy and guidance and The Joint Commission (T JC) standards ·

duties and ultimately causes stress and frustration with the workforce because there is no pay for the additional work performed.

d. KACH Command Climate. The inspection team surveyed employees attending sensing sess!ons with a questionnaire specifically focused on command team involvement, fear of reprisal, and employee behavior and administration.

The survey consisted of 20 statements with response options from "Strongly Agree" to "Strongly Disagree." 130 KACH personnel voluntarily tO'ok the survey over a four-day period. The results strongly suggest there are significant issues that KACH leadership needs to address.

Most concerning were results that showed 62% of those taking the survey "Disagreed" or "Strongly Disagreed" with the statement, 'The command climate at Keller Army Community Hospital (KACH) is good." Moreover, in response to the statement, "Hospital leadership is involved in day-to~day operations," 46% "Disagreed" or "Strongly Disagreed" with the statement, and 16% chose "Did Not KnoW' if leadership was involved, a net of over half of the sampled group. Respondents who provided written inputs were careful to point out that their comments were not directed at the current leadership but were based on their experience with the previous two command groups. Several highlighted that they already see positive changes under the new leadership and one employee noted, 'We have already seen the new commander more than we saw the previous two commanders combined."

Analysis of the survey responses led to the conclusion that communieation problems exist within KACH that have spawned informal communication channels and misinformation. Previous formal communication channels appear to have been inadequate t<;> address the hospital staffs needs. Without a reliable communications structure, originating from within the command group, employees are left to share information obtained principally through hearsay and rumor generated by unreliable sources leading to misinformation. An example: hospital employees believed a programmed small hospital study meant the closure of KACH. This story was further exacerbated by rumors speculating that the stalled MILCON projects, plus the belief that the former commander was considering transitioning from a full-service hospital to an outpatient clinic, were additional signs that significant changes were on the horizon.

Simultaneous turnover of the chain of command within KACH has been the norm for many years. MEDCOM and the US Army Human Resources Command (HRC) routinely reassigned the sitting Commander, Command Sergeant Major, Deputy Commander for Clinical Services (DCCS), Deputy Commander for Nursing (DCN) and

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Deputy Commander for Adl'llinistration (DCA) during the early summer and replaced the entire hospital senior leadership within 30-45 days of each other. This led to the misperception that there were several long-standing permanent employees "running the place" while the new leadership was learning how the organization functioned. This misperception was further aggravated when these same select employees had direct access to the new leadership. Such turnover at KACH has created an environment where some long-term, inflexible employees will "wait the command out," and attempt to influence the new command team.

7. Key Findings. The inspection found 13 findings (four deficiencies and nine observations). The most significant are below:

a. Deficiency: Employee Competency Assessment Files (six-part folders) are not up to date.

b. Deficiency: MEDCOM reimbursable positions are not being used exclusively by CPAC servicing West Point supporting KACH requirements for recruiting, classification, management I employee relations and training.

c. Deficiency: The CPAC servicing West Point, Northeast Region CHRA and CHRA headquarters are failing to apply adequate quality control and oversight of personnel actions, resulting in one regulatory and numerous procedural findings.

d. Observation: MEDDAC Reg 15-1 committees are not functioning IAW AR 40-68.

e. Observation: There is a work stoppage of MILCON Project #59220 (KACH Expansion).

f. Observation: The CPAC servicing West Point is inadequately manned to support client needs in compliance with the Office of Personnel Management (OPM) timelines.

g. Observation: KACH Command Climate Survey data is concerning.

8. Verification. TBD.

9. Key Recommendations. The inspection team made 29 recommendations. The below recommendations correspond to the Key Findings above.

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a. Commander, MEDCOM: (1) Develop and publish a policy to standardize minimum requirements and

establish inspectable items for all MEDDAC Regulations 15-1.

(2) Direct Regional Medical Commands to provide a T JC mock survey 18 months before MTFs' next T JC Survey.

(3) Establish minimum requirements for RMCs to conduct annual reviews of MEDDAC CAFs.

(4) Ensure RMCs conduct Initial I Subsequent Command Inspections. Ensure RMC commanders are apprised of the results of subordinate commanders' command climate surveys IAWAR 600-20.

(5) Explore options to avoid simultaneous turnover of hospital command teams, to include deputies, across MEDCOM in order to provide continuity of leadership for MTFs.

(6) Consider the addition of a civilian executive officer position to the Tables of Distribution and Allowances (TOA) for hospitals under MEDCOM to provide civilian leadership and continuity within all MEDCOM hospitals.

b. Director, CHRA:

(1) Review staffing and ensure CPAC servicing West Point is adequately manned to support United States Military Academy, KACH, and CHRA West Point HR actions based on West Point service population.

(2) Explore standing up a virtual office to support KACH from another geographic location to be able to obtain a full performance HR Specialist.

(3) Ensure the CPAC servicing West Point places all HR Specialist trainees on the CHRA approved Individual Development Plan (IDP) and that trainees receive appropriate oversight and training from CPAC supervisors.

(4) Consider requesting OPM re-evaluate the current locality adjustment rate pertaining to the West Point area to determine sufficiency.

(5) ICW all reimbursable partners {to include MEDCOM), ensure there is full funding and full compliance with support agreements.

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(6) Adjudicate improper hiring actions discovered during the inspection.

(7) Ensure there is compliance with CHRA policies and procedures through appropriate oversight and quality review.

c. Commander, USACE, report on the resumption of work when it occurs on MILCON project #59220 and provide regular updates to Army leadership.

d. Commander, KACH:

(1) Enforce KACH MEDDAC Reg 15-1 and ensure minutes provide actionable information.

(2) Update and maintain CAFs IAW AR 40-68.

10. Current and Ongoing Actions:

a. Action #1: USACE has successfully negotiated with the Surety Company to take over the stopped project and restart work in September 2014 to allow beneficial occupancy of the facility by Summer 2015. Upgrades related to the inpatient and, most critically, to the outpatient clinics, are being addressed by the MILCON project.

b. Action #2: MEDCOM is reviewing the current MEDDAC command team rotation schedule in order to eliminate simultaneous turnover of key MTF positions.

c. Action #3: Director, CHRA has addressed 20 of the 21 deficiencies found in the inspection. Of the twenty, seven have been corrected, and 13 are in progress.

d. Action #4: Director, CHRA has realigned the MEDCOM funded positions at CPAC supporting West Point to ensure they fully support Memorandum of Agreement requirements. CHRA is further reviewing all reimbursable positions across the Army.

11. Conclusion. The DAIG Sii inspection revealed no evidence of any issue at KACH that would negatively impact patient safety. Issues and concerns raised by the letter had some merit, but a lack of effective communication and a poor command climate contributed significantly to the identified problems. Absence of oversight and a lack of standardization contributed to issues with MEDDAC Reg 15-1 committees and CAF compliance. Oversight of policy and training across the board will address many of the team's findings. The MILCON work stoppage precluded essential repairs and

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SAIG-ZA SUBJECT: Special Interest Item (Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and Department of Defense (DoD) policy and guidance and The Joint Commission (TJC) standards

reinforced a perception that the hospital was either closing or eliminating some services. The restart of the project, however, will improve both hospital conditions and morale and will eliminate the source of many rumors. Current hiring practices and policies are also having a negative impact on hospital operations. Better oversight and training can mitigate these difficulties and management challenges. USACE, MEDCOM and CHRA are already taking key steps to correct known deficiencies and observations.

~~~ LTG, USA The Inspector General

DISTRIBUTION: THE AUDITOR GENERAL . DEPUTY CHIEF OF STAFF, G-1, CIVILIAN HUMAN RESOURCES AGENCY CHIEF OF ENGINEERS THE SURGEON GENERAL SUPERINTENDENT, UNITED STATES MILITARY ACADEMY

CF: COMMANDER, NORTHERN REGIONAL MEDICAL COMMAND COMMANDER, KELLER ARMY COMMUNITY HOSPITAL

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\

SAIG-ZA SUBJECT: Enclosure 1 (Verification Matrix) to Memorandum, Special Interest Item {Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards.

1. Verification. The below listed stakeholder organization(s) have been provided a briefing of the inspection report findings and recommendations for verification and comment. The intent of this process is to ensure the inspection report is correct .and to capture stakeholder's comments in the final report. The enclosure to this memorandum identifies the (stakeholder/responsible entity) and date briefed followed by a matrix containing all observations, findings, recommendations and concurrence or nonconcurrence. There are 13 findings (five Deficiencies, eight Observations) resulting in 28 unique recommendations on the Secretary of the Army memorandum representing all of the findings from the objectives.

2. Organization USMA KACH Dir, CPAC NRMC USACE A-DIR, CHRA MEDCOM

3. COMMENTS:

Stakeholder LTG Caslen COL (b)(6J & (bJ(7J(CJ

(b)(6) & (b)(7)(C)

BG Tenhet MG Stevens j{b){6) & (b)(7)(C) I MG Lein

Briefing Date 20140812 20140812 20140812 20140813 20140813 20140814 20140814

Comment (see below) Concur 0

Concur Concur Concur Concur w/ Comment 1

Concur w/ Comment 2

Concur w/ Comment 3

0 USMA Superintendent objected to verbiage referencing CPAC-West Point as being inaccurate since he does not own/control the organization. We implemented revised language which now reads "CPAC servicing West Point." Since this affected no recommendations, we address their position as Concur.

1 Based on USACE request since MILCON Project #59220 (KACH Addition) work stoppage has been resolved, the recommendation that "CDR, USAGE /CW CDR MEDCOM present timeline with major milestones in briefing to SecArrny, "was changed to "CDR USA CE, report on the resumption of work when it occurs on MIL CON project #59220 and provide regular updates to Army leadership." - Accepted

2 CHRA provided additional discussion points for inclusion in the report. Acting Director requested the team include new recommendation that "CHRA Director, consider exporting HR Supervisors course developed for Womack ACH to other organizations." -Accepted

3 Deputy Commander, MEDCOM, opined concerning recommendation, "CDR MEDCOM consider providing T JC mock survey 18 month before MTF's next T JC survey" that the tasking and resourcing of T JC surveys should be a Regional Medical Command (RMC) responsibility. As Northern RMC is responsible for KACH, the tasking should go to that RMC. Since the recommendation is intended to address not just KACH but all hospitals, all RMCs would have similar involvement. The team adapted

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SAIG-ZA SUBJECT: Enclosure 1 (Verification Matrix) to Memorandum, Special Interest Item (Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint' Commission standards.

language to read , "CDR MEDCOM, direct RMCs to consider providing TJC mock survey 18 month before MTF's next TJC survey." Deputy Commander, MEDCOM requested we add two new recommendations:

"CDR, MEDCOM, explore options to avoid simultaneous turnover of hospital command teams, to include deputies, across the MEDCOM in order to provide continuity of leadership for MTFs" - Accepted

"CDR, MED COM, consider the addition of a civilian executive officer position to the tables of distribution and allowances for hospitals under the MEDCOM to provide civilian leadership and continuity within all MEDCOM hospitals." - Accepted

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SAIG-ZA SUBJECT: Enclosure 1 (Verification Matrix) to Memorandum, Subject: Special Interest Item (Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission (T JC)standards.

I - RECOMMENDATION(S) Stakeholder(s) Brief

Comment FINDING(S) Date Obiective 1: Policy & Trainina

Concur USMA (20140812) 1.1.1 (Reference #10-1406.01.01): CDR MEDCOM, KACH (20140812) Concur ::levelop and publish a policy to standardize minimum Dir CPAC (20140812) Concur requirements and establish inspectable items for all NRMC (20140813) Concur MEDDAC Regulations 15-1. MEDCOM (20140814) Concur

USMA (20140812) Concur 1.1.2 (Reference #ID-1406.01.02): CDR MEDCOM,

KACH (20140812) Concur 1.1 OBSERVATION (Reference #10-1406.01): KACH !direct Regional Medical Commands to consider

Dir CPAC (20140812) Concur MEDDAC Regulation 15-1 committees not functioning providing a TJC mock survey 18 month before an MTF's NRMC (20140813) Concur IAWAR40-68 next T JC survey.

MEDCOM (20140814) Concur w/ Cmt

1.1.3 (Reference #10-1406.01.03): CDR KACH, USMA (20140812) Concur ~nforce KACH MEDDAC Reg 15-1 , paragraph 6g and KACH (20140812) Concur Illustration 4, and ensure minutes provide actionable Dir CPAC (20140812) Concur information. NRMC (20140813) Concur

MEDCOM (20140814 Concur

USMA (20140812) Concur

1.2.1 (Reference #ID-1406.02.01): CDR MEDCOM, KACH (20140812) Concur

establish clear standards for PSRs and update AR 40- Dir CPAC (20140812) Concur

68 as applicable. NRMC (20140813) Concur 1.2 OBSERVATION (Reference #ID-1406.02): MEDCOM (20140814) Concur Submission requirements for Patient Safety Reports

USMA (20140812) Concur PSR) not clearly defined in AR 40-68. KACH (20140812) Concur

1.2.2 (Reference #10-1406.02.02): CDR KACH, Dir CPAC (20140812) Concur !establish a PSR SOP for the organization. NRMC (20140813) Concur

MEDCOM (20140814) Concur

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SAIG-ZA SUBJECT: Enclosure 1 (Verification Matrix) to Memorandum, Subject: Special Interest Item (Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission (T JC) standards.

FINDING($) RECOMMENDATION($) Stakeholder(s)

Comment Brief Date USMA (20140812) Concur

1.3.1 (Reference #ID-1406.03.01): CDR MEDCOM, KACH (20140812) Concur !establish minimum requirements for RMCs to conduct Dir CPAC (20140812) Concur

1.3 DEFICIENCY (Reference #10-1406.03): annual review s of MEDDAC CAFs. NRMC (20140813) Concur

Competency Assessment Files (six-part folders) are not MEDCOM (20140814) Concur

up-to-date. USMA (20140812) Concur

1.3.2 (Reference #10-1406.03.02): CDR KACH, KACH (20140812) Concur update and maintain the CAFs IAW AR 40-68. Dir CPAC (20140812) Concur

NRMC (20140813) Concur MEDCOM (20140814 Concur

USMA (20140812) Concur 1.4.1 (Reference #10-1406.04.01): CDR MEDCOM, KACH (20140812) Concur prioritize and establish Army-specific training DirCPAC (20140812) Concur

1.4 OBSERVATION (Reference #10-1406.04): KACH requirements applicable to civilian and military NRMC (20140813) Concur

!employees are required to take redundant or non-personnel. MEDCOM (20140814} Concur

iapplicable training . USMA (20140812) Concur 1.4.2 (Reference #10-1406.04.02): CDR KACH, KACH (20140812) Concur review, evaluate and schedule required training IAW AR Dir CPAC (20140812) Concur 350-1 and MEDCOM policies. NRMC (20140813) Concur



1.5 OBSERVATION (Reference #10-1406.05): 1.5.1 (Reference #ID-1406.05.01 ): CDR KACH, KACH (20140812) Concur

~vailable training aids are not being effectively used to coordinate for MTis to provide proficiency in using DirCPAC (20140812) Concur

maintain proficiency in critical skills. critical skills training aids. NRMC (20140813) Concur MEDCOM (20140814 Concur

USMA (20140812) Concur 1.6.1 (Reference #10-1406.06.01): CDR KACH, update KACH (20140812) Concur

1.6 DEFICIENCY (Reference #10-1406.06): Paper iand publish an overtime policy and inform the Dir CPAC (20140812) Concur ~ime card systems do not accurately reflect the hours iworkforce. NRMC (20140813) Concur !employees are working. MEDCOM (20140814 Concur

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. FINDING(S) RECOMMENDATION{S) Stakeholder(s) Brief

Comment Date Objective 2: Infrastructure & Sanitation


12.1 OBSERVATION (Reference #10-1406.07): Work 2.1.1 {Reference #10-1406.07.01): CDR USACE, KACH (20140812) Concur

!Stopped on the Keller Army Community Hospital report on the resumption of work when it occurs on Dir CPAC (20140812) Concur

~KACH) military construction (MILC.ON) project #59220 MILCON project #59220 and provide regular updates to USACE (20140813) Concur w/ Cmt IArmy leadership. NRMC (20140813) Concur


2.2.1 (Reference #10-1406.08.01): CDR KACH , make USMA (20140812) Concur

2.2 OBSERVATION (Reference #10-1406.08.01): KACH (20140812) Concur There is no command oversight of planned utility planning and executing non-emergency utility Dir CPAC (20140812) Concur ~hutdowns.

shutdowns a deliberate event with command NRMC (20140813) Concur involvement. MEDCOM (20140814) Concur

Objective 3: Infrastructure & Sanitation

3.1.1 (Reference #10-1406.09.01 ): Director, CHRA USMA (20140812) Concur KACH (20140812) Concur

review staffing and ensure the CPAC servicing West Dir CPAC (20140812) Concur Point is adequately manned to support United States NRMC (20140813) Concur Military Academy, KACH , and CHRA West Point HR MEDCOM (20140814) Concur actions based on the West Point service population. CHRA (20140814) Concur

3.1.2 (Reference #10-1406.09.02): Director, CHRA USMA (20140812) Concur

3.1 OBSERVATION (Reference #10-1406.09): The KACH (20140812) Concur Civilian Personnel Advisory Center (CPAC) servicing explore standing up a virtual office to support KACH Dir CPAC (20140812) Concur West Point is inadequately manned to support client from another geographic location to be able to obtain a NRMC (20140813) Concur needs in compliance with Office of Personnel full performance level HR Specialist. MEDCOM (20140814) Concur Management (OPM) timelines. CHRA (20140814) Concur

~.1.3 (Reference #ID-1406.09.03): Director, CHRA USMA (20140812) Concur ensure the CPAC servicing West Point places all HR KACH (20140812) Concur Specialist trainees on the CHRA approved Individual Dir CPAC (20140812) Concur Development Plan (IDP) and that trainees receive NRMC (20140813) Concur

' appropriate oversight and training from the CHRA West MEDCOM (20140814) Concur Point CPAC Supervisor. CHRA (20140814) Concur

1-5 For Official Use Ont\ (FOUO)

Dissemination is prohibited except a\ authorized by AR 20-1 .


FINDING(S) RECOMMENDATION(S) Stakeholder(s) Brief

Comment Date

3.1 OBSERVATION (Reference #10-1406.09): The USMA (20140812} Concur Civilian Personnel Advisory Center (CPAC} servicing 3.1.4 (Reference #10-1406.09.04): Director, CHRA KACH (20140812} Concur West Point is inadequately manned to support client consider requesting OPM to re-evaluate the current Dir CPAC (20140812} Concur needs in compliance with Office of Personnel locality adjustment rate pertaining to the West Point NRMC (20140813) Concur Management (OPM) timelines. (Continued) area to determine sufficiency. MEDCOM (20140814) Concur

CHRA (20140814) Concur USMA (20140812} Concur

13.2 DEFICIENCY (Reference #10-1406.10): US Army 3.2.1 (Reference #10-1406.10.01 ): Director, CHRA KACH (20140812} Concur Medical Command (MEDCOM) reimbursable positions ICW reimbursable partners (to include MEDCOM), Dir CPAC (20140812) Concur are not being used by CHRA West Point CPAC to review reimbursable positions to ensure they are fully NRMC (20140813) Concur exclusively support KACH requirements. funded and fully compliant with support agreements. MEDCOM (20140814) Concur

CHRA (20140814) Concur USMA (20140812} Concur

3.3.1 (Reference #10-1406.11.01 ): Director, CHRA KACH (20140812) Concur

Dir CPAC (20140812) Concur adjudicate improper hiring action concerning veterans NRMC (20140813) Concur

~.3 DEFICIENCY (Reference #10-1406.11): CPAC preference. MEDCOM (20140814) Concur servicing West Point, NE Region CHRA, and CH RA-HQ CHRA (20140814) Concur fail to apply adequate quality control and oversight of

USMA (20140812) Concur personnel actions, resulting in one regulatory and numerous procedural findings. 3.3.2 (Reference#ID-1406.11.02): Director, CHRA KACH (20140812) Concur

iensure compliance with CHRA policies and procedures Dir CPAC (20140812) Concur hrough appropriate oversight and quality review. NRMC (20140813) Concur

MEDCOM (20140814) Concur CHRA (20140814) Concur

3.4.1 (Reference #10-1406.12.01 ): Commander, USMA (20140812) Concur MEDCOM and Superintendent US Military Academy KACH (20140812) Concur

3.4 DEFICIENCY (Reference #10-1406.12): Numerous reiterate requirement to all subordinate commands that Dir CPAC (20140812) Concur KACH employees perform dual or triple hatted functions ~upervisors and rated personnel conduct a NRMC (20140813} Concur lhat are not included in the individual's position comprehensive review of all Department of the Army MEDCOM (20140814) Concur k:1escription Civilians' duties and position descriptions for accuracy CHRA (20140814) Concur

ias needed when changes occur and at the time of their annual performance evaluations.

1-6 For Official Use On~ (FOUO)

Dissemination is prohibited except a\ authorized by AR 20-1.

SAIG-ZA SUBJECT: Enclosure 1 (Verification Matrix) to Memorandum, Subject: Special Interest Item (Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission (T JC) standards. ·

RECOMMENDATION(S) Stakeholder(s) Brief

Comment FINDING($) Date

USMA (20140812) Concur KACH (20140812} Concur

IJ.4.2 (Reference #10-1406.12.02): CDR KACH, Dir CPAC (20140812} Concur review TDAs to ensure they have identified accurate NRMC (20140813) Concur positions required to perform mission. MEDCOM (20140814) Concur

CHRA (20140814} Concur USMA (20140812) Concur

3.4.3 (Reference #ID-1406.12.03): Director, CHRA KACH (20140812) Concur -~.4 DEFICIENCY (Reference #10-1406.12): Numerous iconsider exporting HR Supervisors course developed Dir CPAC (20140812) Concur KACH employees perform dual or triple hatted functions ~or Womack Army Community Hospital to other NRMC (20140813) Concur lthat are not included in the individual's position organizations. MEDCOM (20140814) Concur !description. (Continued)

CHRA {20140814) Concur wt Cmt USMA (20140812) Concur

3.4.4 (Reference #ID-1406.12.04): Director, CHRA KACH (20140812) Concur ICW CPAC Director servicing West Point, provide Dir CPAC (20140812) Concur quarterly training to their customers based on customer NRMC (20140813) Concur needs (classification; staffing; MER; performance MEDCOM (20140814) Concur objectives; hiring strat~ies) . CHRA (20140814) Concur

Objective 4: Command Climate

14.1.1 (Reference #ID-1406.13.01 ): CDR ME DC OM, USMA (20140812) Concur ~nsure Regional Medical Commands (RMC} conduct KACH (20140812) Concur initial command inspections and subsequent command Dir CPAC (20140812) Concur inspections IAWAR 1-201. Ensure RMC commanders NRMC (20140813) Concur are apprised of the results of subordinate commanders' MEDCOM (20140814 Concur

14.1 OBSERVATION (Reference #ID-1406.13): !Command climate surveys IAW AR 600-20. !Command climate survey data is concerning.

14.1.2 (Reference #10-1406.13.02): CDR MEDCOM, USMA (20140812) Concur

explore options to avoid simultaneous turnover of KACH (20140812) Concur

hospital command teams, to include deputies, across Dir CPAC (20140812) Concur

~he MEDCOM in order to provide continuity of NRMC (20140813) Concur

leadership for military treatment facilities. MEDCOM (20140814 Concur w/ Cmt

1-7 ~ For Official Use 0 y (FOUO) Dissemination is prohibited except s authorized by AR 20-1 .


FINDING(S) RECOMMENDATION(S) Stakeholder(s) Brief

Comment Date

14.1.3 (Reference #10-1406.13.03): CDR MEOCOM, USMA (20140812) Concur

consider the addition of a civilian executive officer KACH (20140812) Concur

position to the tables of distribution and allowances for Dir CPAC (20140812) Concur

hospitals under the MEDCOM to provide civilian NRMC (20140813) Concur

leadership and continuity within all MEDCOM hospitals. MEDCOM (20140814 Concur w/ Cmt

14.1 OBSERVATION (Reference #10-1406.13): Command climate survey data is concerning. USMA (20140812) Concur (Continued) 14.1.4 (Reference #10-1406.13.04): CDR KACH, review KACH (20140812) Concur

results of previous DEOCS Command Climate Surveys Dir CPAC (20140812) Concur land results of DAIG survey to mitigate the issues NRMC (20140813) Concur identified by the surveys and conduct command climate MEDCOM (20140814 Concur survey at a later date to be determined to measure changes.

1-8 . For Official Use On}y (FOUO)

Dissemination is prohibited except~ authorized by AR 20-1.

SAIG-ZA SUBJECT: Enclosure 2 (Inspection Objective 1 - Policy and Training) to Memorandum, Special Interest Item (Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards

INSPECTION OBJECTIVE 1: Assess the adequacy of Keller Army Community Hospital (KACH) policy and training with regard to hospital operations

SUMMARY OF FINDINGS: The cornerstone of Army hospital management and administration is founded on departmental and inter-departmental committee activity. Keller Army Community Hospital's (KACH) Medical Activity (MEDDAC) Regulation 15-1 (Boards, Committees, Conferences and Councils), 2 June 2014, paragraph 6 requires the medical treatment facility (MTF) to hold committee meetings on a regular basis and to keep minutes and tracking logs. Through discussions and review of committee minutes, the inspection team found that a significant number of feeder committees were not meeting as frequently as required by KACH's own MEDDAC Regulation 15-1 (monthly I quarterly). Attendance by committee members was lacking , and a review of committee minutes showed insufficient level of detail to track committee activities. Further, information flow up and down the committee structure was not always evident. During discussion with MTF staff, it was reported that there is no formal process in place to staff policy or procedure changes.

KACH currently has no policy or standard operating procedures (SOP) in place regarding submission requirements of a Patient Safety Report (PSR) . PSRs are required for "the reporting of safety events from near-misses to harm events" (Memorandum, U.S. Army Medical Command, MCHO-CL-Q, 19Nov10, subject: Implementation of the Department of Defense (DoD) Patient Safety Reporting System (PSR)) . Generally, PSRs are only completed at KACH when an adverse event (event causing harm to a patient) occurs. The intent of submitting a PSR is for the committee to meet and review each PSR and to discuss the outcome. Providing feedback of the outcome promotes a learning environment. The Patient Safety committee meeting minutes lacked sufficient detail to track PSRs, committee activities, and outcome I resolution of discussion of the event. Enforcement and oversight was Jacking within KACH, the Regional Medical Command (RMC) and the US Army Medical Command (MEDCOM) headquarters.

Training was assessed through review of the Competency Assessment Files (CAF). The CAFs document full competency of each individual to perform their duties. The files reviewed lacked required documentation of competency assessments per AR 40-68, chapter 8, since 2012. Many of the required certification validations (Basic Life Support, Advanced Cardiovascular Life Support, licensure, etc.) were not current. Several of the files lacked orientation to the work site .

If left uncorrected, the deficiencies identified above put the credentialing of KACH at risk during the next Joint Commission survey.

2-1 ~ For Official Use Onl (FOUO) Dissemination is prohibited except as authorized by AR 20-1


1.1 OBSERVATION (Reference #10-1406.01): KACH MEDDAC Regulation 15-1 committees not functioning IAW AR 40-68.

ROOT CAUSE: Won't Comply

DISCUSSION: Per AR 40-68, paragraph 2-1, The Joint Commission (TJC), the body that accredits hospitals, requires an organized, self-governing medical staff to provide direction and oversight of the quality of care, treatment, and services delivered by privileged providers. AR 40-68, paragraph 2-5, states that T JC "requires the medical staff to provide leadership in measuring, assessing, and improving processes that primarily depend on the activities of privileged providers, as well as participating in organization-wide performance improvement (Pl) activities." MTFs meet this requirement through the establishment of a Performance Improvement Committee (PIC). KACH MEDDAC Regulation 15-6 mandates the PIC as one of its committees.

AR 40-68, paragraph 2-6, states that T JC "requires an Executive Committee of the Medical Staff (ECMS) (or committee with a similar function)." It also states, "The following committees/functions are required by this regulation)" and lists those mandatory committees as the Executive Committee, the Patient Safety Committee, the Risk Management Committee, the Credentials Committee, and the Impaired Healthcare Personnel Committee. All mandatory committees other than the Impaired Healthcare Personnel Committee are mandated by KACH MEDDAC Regulation 15-1.

In accordance with AR 40-68, paragraph 2-6g, "Various committees, boards, and councils may be established with the approval of the executive committee to perform the monitoring and evaluation required in paragraph 2-5 of this regulation and other relevant guidance ... " In response to this requirement, KACH has established several other committees in KACH MEDDAC Regulation 15-1 to perform those functions stated in AR 40-68, paragraph 2-5. AR 40-68, paragraph 2-6h requires that "(a) written record of all clinical quality management (CQM) committees I functions will be maintained by the MTF."

KACH, like all other Army MTFs, has its own MEDDAC Regulation 15-1 or equivalent regulation that is intended to demonstrate self-governing by providing details about how the MTF leadership intends on operating the technical aspects of their facility in compliance with MEDCOM and Department of Defense (DoD) guidance. KACH MEDDAC Regulation 15-1, paragraph 6 articulates policies and procedures for committees, structure requirements, meeting frequency, membership and other suggested attendees, general meeting minutes, requirements and committee output requirements at KACH. Although signed by the MTF Commander and published and distributed within the MTF, our interviews consistently demonstrated that many committees are not meeting these requirements in terms of frequency and attendance,

2-2 ~ For Official Use 0 ly (FOUO) . Dissemination is prohibited except as authorized by AR 20-1


particularly those committees that serve as feeders to the five Executive Committees. Interviewees stated that they were members of one or more committees, but one or more of those committees met only once or twice in the past year.

During the inspection, KACH MEDDAC Regulation 15-1 and minutes from various committees were reviewed, to include the Quality Management committee, the Executive Committee of Medical Staff, the Patient Safety committee, and the Environment of Care committee. Discussion with key leaders of the KACH staff on KACH MEDDAC Regulation 15-1 and committees focused on task and purpose of the committees, committee members and attendance, meeting minutes details, and tracking logs.

Through discussions and review of committee minutes, the inspection revealed that committees were not meeting as frequently as required by KACH MEDDAC Regulation 15-1 (monthly I quarterly). For example, one committee was required to meet quarterly but only met once within the past year. Attendance as documented in meeting minutes sometimes did not include attendance by mandatory committee members, and committee meeting minutes lacked sufficient detail to track committee activities and were not consistent with the requirements of KACH MEDDAC Regulation 15-1, paragraph 6g and Illustration 4. Also, sharing of information up and down the committee structure was not always evident. Staff members stated that no process was in place to staff policies and procedures.

The committee structure is a key component to the decision process and procedures for running the hospital organization. It allows transparency and communication flow within the organization. This concept ensures decisions are made with key staff at the table and that these decisions and recommendations are captured to share with the organization. If properly operationalized, it can be used during T JC survey to demonstrate the processes in which decisions are made, information is shared, and the organization operates to allocate resources, make decisions, and communicate. This committee structure supports a learning organization concept-model and will give structure to the organization .

RECOMMENDATIONS:

1.1.1 (Reference #ID-1406.01.01 ): CDR MEDCOM, develop and publish a policy to standardize minimum requirements and establish inspectable items for all MEDDAC Regulations 15-1 .

1.1.2 (Reference #ID-1406.01.02): CDR MEDCOM, direct Regional Medical Commands to consider providing a T JC mock survey 18 months before an MTF's next T JC survey.

2-3 . For Official Use oJy (FOUO)

Dissemination is prohibited except(as authorized by AR 20-1


1.1.3 (Reference #10-1406.01.03): CDR KACH, enforce KACH MEDDAC Reg 15-1, paragraph 6g and Illustration 4, and ensure minutes provide actionable information.

STANDARDS:

The Joint Commission - Comprehensive Accreditations Manual for Hospital (CAMH), 15 December 2012;

DoDI 6025.13 (Medical Quality Assurance (MQA) and Clinical Quality Management in the Military Health System (MHS)), 17 February 2011, Enclosure 3;

AR 40-68 (Clinical Care Management), 27 February 2004, RAR 22 May 2009, Chapter 2;

AR 40-61 (Medical Logistic Policies), 28 January 2005, paragraphs 1-13c, 3-17c, Paragraphs 6-5a(2) & 7-3d;

KACH MEDDAC Regulation 15-1 (Board, Committees, Conferences and Councils), 2 June 2014.

1.2 OBSERVATION (Reference #ID-1406.02): Submission requirements for Patient Safety Reports (PSR) not clearly defined in AR 40-68.

ROOT CAUSE: Can't Comply

DISCUSSION: The Patient Safety Program is an integral part of the MTF's process. It includes assessment, identification, classification, and management of the analysis and reporting, as appropriate, of health care associated sentinel events (death or serious physical or psychological injury to a patient, (e.g. loss of limb or death)), adverse events (caused harm to a patient) and close calls (potential harm to a patient).

Discussion with various employees indicated that the KACH members did not routinely submit a DA Form 4106 (Incident Report), or an equivalent report, for adverse events or close calls as required by AR 40-68, paragraph 12-4b(1). Nor was the KACH routinely using the PSR system, mandated by a MEDCOM memorandum dated 19 November 2010, Subject: Implementation of the Department of Defense (DoD) Patient Safety Reporting System (PSR). This memorandum required all MEDCOM Regional Medical Commands to use this web-based anonymous reporting system to report "patient safety events from near-misses [close calls] to harm events." MEDCOM mandated full implementation of this system by May 2011. The automated PSR system is accessible

2-4 ~ For Official Use Onl (FOUO) Dissemination is prohibited except s authorized by AR 20-1

SAIG-ZA SUBJECT: Enclosure 2 (Inspection Objective 1 - Policy and Training) to Memorandum, Special Interest Item (Sil) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards

through the US Army Medical Department Office of Quality Management website at https://www.gmo.amedd.army.mil/ptsafety/pts.htm.

In accordance with AR 40-68, paragraph 12-2b, "In order to sustain a culture of safety within the [Army Medical Department] AMEDD, enhanced responsibility and accountability for PS [patient safety] at all levels of the organization is essential. Leadership must establish an atmosphere of trust and confidence that encourages all staff to report actual and potential medical I healthcare errors in order to protect patients, to learn from the hazardous situations identified, and, wherever possible, to prevent future recurrences." Where regulations are vague on patient safety reporting, commanders must establish a local policy regarding PSRs.

Although AR 40-68, paragraph 12-3, required MTF commanders to publish a policy implementing a Patient Safety Program, there was no hospital policy in effect at the time on submission requirements for a PSR. The intent of submitting a PSR is to improve patient safety and to reduce risk to patients through an environment that recognizes risk to patient safety. It initiates actions to reduce risk and focuses on processes and systems.

KACH members generally submitted PSRs only for a sentinel event (an unexpected occurrence involving death or serious physical or psychological injury to a patient, or the risk thereof, that is not related to the natural course of the patient's illnesses or underlying condition) or an adverse event (an occurrence or condition associated with the provision of care or services that caused harm I injury to the beneficiary). Local commanders have wide latitude in establishing policy for when a PSR must be submitted for a close call (an event or situation that could have resulted in harm to the patient but did not, either by chance or through timely interiention). KACH personnel report that they follow the guidelines and procedures of MEDCOM Regulation 40-41 (The Patient Safety Program), 8 May 2013, with regard to patient safety. However, like AR 40-68, that publication provides no additional guidelines for what types of events generate a PSR. AR 40-68 does not clearly define a close call, and because of the absence of PSR policy at KACH, a potentially compensable event (an adverse event that occurs in the delivery of healthcare and services with resulting beneficiary harm, including any adverse event or outcome, with or without legal fault, in which the patient experiences any unintended or unexpected negative result) did not result in the submission of a PSR because the staff did not consider the event to be a close call.

The Patient Safety Program requires a Patient Safety Committee to meet monthly to ensure that health care issues are identified for the purpose of tracking, trending and analyzing on a monthly or as-needed basis. Providing feedback of the outcome promotes a learning environment, which supports the knowledge sharing to affect behavioral change. The Patient Safety Committee meeting minutes reviewed during the

2-5 ~ For Official Use Onl (FOUO) Dissemination is prohibited except a authorized by AR 20-1


inspection lacked sufficient detail to track PSRs, committee activities, and the outcome I resolution of patient safety incidents.

RECOMMENDATIONS:

1.2.1 (Reference #10-1406.02.01): CDR MEDCOM, establish clear standards for PSRs and update AR 40-68 as applicable.

1.2.2 (Reference #ID-1406.02.02): CDR KACH, establish a PSR SOP for the organization.

STANDARDS:

AR 40-68 (Clinical Quality Management), 26 February 2004, RAR 22 May 2009, Chapter 12;

MEDCOM Regulation 40-41 (The Patient Safety Program), 8 May 2013;

MEDCOM Memorandum, Subject: Implementation of the Department of Defense (DoD) Patient Safety Reporting System (PSR), 19 November 2010.

1.3 DEFICIENCY (Reference #ID-1406.03): Competency Assessment Files are not up-to-date.

ROOT CAUSE: Won't Comply - lack of oversight.

DISCUSSION: Competency assessments are required of all members of the staff and are demonstrated by one's performance in a designated setting. Performance must meet established standards that are determined, in part, by the work setting and the employee's designated role in that setting. Thus, the leaders of an organization must clearly define the qualifications and competencies that staff must possess to accomplish the organization's mission. The Competency Assessment File (CAF) is a six-part folder that documents all items that were considered by MTF leadership in granting privileges to hospital personnel in order for them to perform hospital missions. KACH Regulation 1-200, Appendix R, provides details and a checklist of exactly which documents will be filed in the CAF and where in the CAF the documents will be filed.

The inspection team reviewed 20 CAFs. All 20 lacked annual competency assessments, and some (6 of 20) lacked training documentation. Common problems included; a lack of certification validation such as Basic Life Support, Advanced Cardiovascular Life Support and licensure. Documentation gaps consisted of missing competency assessments required per AR 40-68 (paragraphs 5-1 / 8-1) and Appendix

2-6 t For Official Use On (FOUO) Dissemination is prohibited except authorized by AR 20-1


R of KACH's MEDDAC Regulation 1-200 as well as formal work area orientations. Folders reviewed were not current and did not appear to have been updated since the last TJC Survey in 2012. AR 40-68, Appendix C requires reviews and updates annually. Each file reviewed had a paper stating that all licenses and certifications were maintained in the Credentials Office in contravention to KACH Regulation 1-200, Appendix R. The paper listed the expiration dates of the licenses and certificates, many of which were expired based upon the data in the CAF. The database in the Credentials Office showed that KACH ensures that employees are up to date on their licenses and certifications, but the CAFs were not updated with the proper expiration dates. Continuing education training was documented in the CAFs, but there were no new training documents in most files since 2012, when the files were updated prior to a Joint Commission inspection.

Several files lacked any documentation of the mandatory newcomers' training and worksite orientation. A file for a nurse who transferred from the Medical Surgical Unit (MSU) to the Emergency Room (ER) four months earlier reflected orientation to the MSU but not to the ER. The lack of documentation of current competencies, appropriate orientation to the worksite, and validation of current licensure I certifications demonstrates a lack of leadership oversight and noncompliance with AR 40-68.

Competency assessment is a critical element of performance for T JC accreditation. TJC looks exclusively at the CAF; deficiencies in three CAFs create a critical finding that jeopardizes accreditation.

RECOMMENDATIONS:

1.3.1 (Reference #ID-1406.03.01): CDR MEDCOM, establish minimum requirements for RMCs to conduct annual reviews of MEDDAC CAFs.

1.3.2 (Reference #ID-1406.03.02): CDR KACH, update and maintain the CAFs IAW AR 40-68.

STANDARDS:

AR 40-68 (Clinical Quality Management), 26 February 2004, RAR 22 May 2009, Appendix C and E;

KACH Regulation 1-200, 6 May 2014, Appendix R, CAF Checklist of Keller Army Community Hospital.

1.4 OBSERVATION (Reference #ID-1406.04): KACH employees are required to take redundant or non-applicable training.

2-7 \ For Official Use On (FOUO) Dissemination is prohibited except s authorized by AR 20-1


DISCUSSION: Interview and sensing session feedback addressed numerous instances where civilians were required to take training intended for military personnel. Some examples include Law of War, Army Values training, and Personnel Recovery and Code of Conduct. Additionally, non-medical personnel were required to take training intended for medical practitioners. One consistent complaint across the MTF was personnel were repeatedly prompted to take and retake the identical training to satisfy Army, garrison, and KACH requirements. Often, mandatory training notifications, such as for the Sexual Harassment I Assault Response and Prevention Program, included a very short suspense without command involvement.

Such issues point to an ineffective training management system and lack of tracking of mandatory and organizationally directed training. In traditional organizations, training is planned and scheduled, and attendance I completion is tracked via the Digital Training Management System (DTMS). This system is web-based and accessible via Army Knowledge Online, and it should be used at the Medical Company. Using the customizable features of DTMS, the individual responsible for DTMS input can identify AR 350-1-required training for all personnel, as well as training requirements specifically for civil ian or military personnel.

DTMS-generated reports demonstrate required training that has occurred and allow hospital leadership to identify and eliminate redundant training, precluding mandatory attendance at training events that are not appropriate for an individual's military occupational specialty (MOS), area of concentration (AOC), or civilian job series. If DTMS operators are not familiar with DTMS and its features, mobile training may be available from the Regional Medical Command.

To support most effective use of DTMS across medical organizations, MEDCOM should ensure that specific training requirements applicable to civilian and military personnel by are available across the command.

RECOMMENDATIONS:

1.4.1 (Reference #ID-1406.04.01): CDR MEDCOM, prioritize and establish Armyspecific training requirements applicable to civilian and military personnel by MOS, AOC or job series.

1.4.2 (Reference #ID-1406.04.02): CDR KACH, review, evaluate and schedule required training IAW AR 350-1 and MEDCOM policies.

STANDARD:

AR 350-1 , Army Training and Leader Development, 19 August 2014. I 2-8

For Official Use O~y (FOUO) Dissemination is prohibited except~s authorized by AR 20-1


1.5 OBSERVATION (Reference #ID-1406.05): Available training aids are not being effectively used to maintain proficiency in critical skills.

DISCUSSION: The inspection team found that Obstetrics owns a NOELLE® birth trainer and an infant IV trainer. Only a couple of KACH personnel were aware of their existence, and none recalled using those items for training. Personnel within the Obstetrics and other treatment departments immediately saw the applicability I utility of the devices. Funding exists to bring trainers to KACH to train personnel on the use of these training aids, but no one requested to bring a mobile training team (MTI) to KACH to provide the training. Even if an MTT is not available, training support packages are available from the manufacturer, and scheduled training events are listed on Gaumard Scientifics' web site at http://www.gaumard .com.

Other personnel interviewed expressed frustrations with the inability to obtain training via medical conferences, which are heavily restricted by DoD Travel Regulations. Much of the continuing education for medical professionals traditionally occurs at events the DoD characterizes as a conference. Although many perceived that attendance at such conferences was no longer allowed, organizations can request to send personnel to these conferences. However, organizations must comply with Office of The Surgeon General (OTSG) I MEDCOM Policy Memo 14-017's timelines and procedures.

KACH is taking advantage of other venues to address continuing education, but travel funds for training attendance are perceived to be limited. In an effort to maintain proficiency, personnel interviewed from a couple of departments within KACH stated that they had requested funds to purchase training materials (instructional DVDs, books, etc.) but had the requests rejected due to lack of funds. The audit shown at Tab A to this objective reveals there are sufficient funds in other accounts that can be reprogrammed to purchase training materials or support travel to attend training events. Departments had not requested reprogramming of available funds to support their training requirements, and several departments turned back funds at the end of FY13 that could have been used to purchase training materials.

RECOMMENDATION:

1.5.1 (Reference #10·1406.05.01): CDR KACH, coordinate for MTTs to provide proficiency in using critical skills training aids.

STANDARD:

OTSG I MEDCOM Policy Memo 14-017, MEDCOM Guidance for Implementation of Army Directive 2014-01 (Army Conference Policy), 28 February 2014.

2-9 For Official Use On\t (FOUO)

Dissemination is prohibited except \s authorized by AR 20-1

SAIG-ZA SUB~ECT: Enclosure 2 (Inspection Objective 1 - Policy and Training) to Memorandum, Special Interest Item (Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards

1.6 DEFICIENCY (Reference #ID-1406.06): Paper time card systems do not accurately reflect the hours employees are working.

ROOT CAUSE: Don't know.

DISCUSSION: During our inspection of KACH, interviewees addressed the following types of concerns pertaining to overtime: 1) Inability to overcome a difficult process to approve overtime in advance; 2) Perception that management did not allow overtime under any circumstances without advance approval; 3) Perception that management did not allow overtime due to funding constraints; and 4) Lack of understanding among employees about overtime policy.

During interviews, budget and human resources personnel stated that requests for overtime required four signatures and had to be approved at least two weeks in advance. Interviewees stated that KACH was still following furlough guidance for overtime; none were aware that MEDCOM has rescinded the policy. Key personnel were also unaware of any other overtime policies, although a local policy for overtime (MEDDAC Regulation 690-990-1) was still in effect.

The overtime process described in MEDDAC Regulation 690-990-1 required signatures from the Supervisor and the Department I Division Chief or Deputy Commander. Interviewees stated that, in practice, overtime approval required all three signatures. During sequestration, overtime required the Commander's approval in addition to the other signatures.

Each employing organization is responsible for controlling overtime. Sensing sessions revealed three concerns: employees are working beyond hours reflected on time cards; employees are working hours off the books and consuming "credit hours" off the books; and supervisors are enforcing a "rule" that if not approved in advance by the established procedure, overtime is not payable. MEDDAC Regulation 690-990-1, section 7b, does in fact make provisions for unscheduled overtime. That guidance requires submission of overtime no later than the next business day after the overtime occurred and provides a listing of situations where this 'might occur. The list includes emergencies involving patient care, emergency repairs, safety, security, substantial cost savings and response to a disaster.

By federal law, whether an employee is Exempt or Nonexempt from Fair Labor Standards Act (FLSA), "All overtime work that is ordered, approved, or suffered or permitted must be compensated in accordance with part 550 or 551, Title 5, Code of Federal Regulations." In other words, if a supervisor or manager directs, approves or knows that the employee works beyond normal hours, the employee is entitled to overtime pay. Detailed guidance on Overtime Pay is in DoD Administrative Instruction

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(Al) Number 28 (Overtime, Prescribed Hours of Duty, and Alternate Work Schedules for Civilian Employees), January 5, 2011 . The inspection team could not document any actual cases of working without compensation, but there were enough discussions of the practice to believe that it is occurring. If employees are working without compensation, such action violates 5 CFR 550 or 5 CFR 551 and DoD Al Number 28. Interviewees sometimes reported the practice of accruing and using credit hours off the books. If an employee is working a Flexible Work Schedule, a formal type of Alternate Work Schedule, this practice is permissible. However, such practice requires establishment of policy, supervisor approval, and accrual and use IAW Enclosure 4 to Al Number 28.

Interviewees told us they could not obtain overtime approval due to funding constraints. This appeared to be a common perception at KACH. Our review of Keller finances did not show financial shortages that would impair compensatory time or payments for overtime.

Employees and supervisors are confused as to KACH's Overtime Policy. MEDDAC Regulation 690-990-1 , Overtime and Compensatory Time Approval Procedures dated 5 October 201 o is still in effect and appears to be compliant with Al Number 28. However, the referenced DA Form 1572-R is expired, and the approval and claim procedures outlined will not apply to the Automated Time Attendance and Production System (ATAAPS) that is about to be adopted by KACH .

RECOMMENDATION:

1.6.1 (Reference #ID-1406.06.01): CDR KACH, update and publish an overtime policy and inform the workforce.

STANDARDS:

DoD Administrative Instruction (Al) Number 28 (Overtime, Prescribed Hours of Duty, and Alternative Work Schedules for Civilian Employees), 5 January 2011, Enclosures 6 - 8;

MEDDAC Regulation 690-990-1 (Overtime and Compensatory Time Approval Procedures), 5 October 201 O;

Title 5, Code of Federal Regulations, Part 550 & 551, Provisions, 2011, Subpart E, Overtime Pay.

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Dissemination is prohibited except s authorized by AR 20-1

SAIG-ZA SUBJECT: Tab A (Financial Audit Feedback) to Enclosure 2 (Policy & Training) to Memorandum, Special Interest Item (Sii) inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards.

1. AUDIT FEEDBACK SUMMARY. The DAIG IG conducted an inspection of Keller Army Community Hospital (ACH) at the US Military Academy (USMA) at West Point, New York from 8 July through 25 August 2014. This included an on-site inspection of KACH from 21 - 28 July 2014. The DAIG briefed the findings to the Hospital Commander and the Senior Commander (Superintendent US Military Academy) on 21 and 22 July respectively.

In support of and simultaneous with the inspection, AAA conducted interviews with the Chief of Resource Management, the Budget Officer and a Senior Budget Analyst. We obtained resource summaries, departmental budgets and additional support documentation for KACH. KACH's historical funding by element of resource for Fiscal Years (FY) 10-14 is shown below.

Element of Resource FY 10 FY 11 FY 12 FY 13 FY 14

Obligations Obligations Obligations Obligations Obligations•

Civilian Pay $22,232,718 $23,404,268 $25,642,566 $25,372,856 $17,771,406

Travel $489,292 $531,916 $371,105 $405,017 $110,520

Transportation, Printing & Rent $130,176 $144,208 $1,015,972 $1,073,620 $600,855

Contracts $8,372,226 $7,877,387 $7,161,293 $19,982,321 $5,001,273

Supplies $3,986,270 $4,187,524 $3,645,729 $3,335,562 $3,210,149 Pharmacy $4,704,025 $3,995,956 $4,753,643 $4,033,478 $2,769,185 Reimbursables ($694,497) ($662,849) ($1,278,919) ($957,357) ($300,458) Equipment $2,623,821 $1,546,813 $1,566,041 $253,248 $329,671 Total Core fundlni for Medical** $41,844,031 $41,025,224 $42,877,431 $53,498,746 $29,492,601

•oata pulled from GFEBS as of 17 Jul 14. Therefore FY 14 obligations don't represent the full year. •*FY 10 data is from STANFINS. FY 11 data is both STANFINS and GFEBS. FY 12-14 data is from GFEBS.

ANNUAL EXPENSES. Each year, the hospital budget and the departmental budgets start with the previous year's expenses. Then budget personnel, in coordination with hospital Command, make adjustments for things that are changing from one year to the next. During execution of a budget year, budget personnel have the ability to re-allocate funds within the hospital in coordination with Command decisions.

The process for making budgetary decisions involves a monthly Program Budget Advisory Committee (PBAC) meeting . We reviewed PBAC minutes from FebruaryJuly 2014. Generally, the PBAC minutes documented decisions, but didn't explain why Command made these decisions or articulate the decision making process. Our analysis of KACH's finances showed several indications that they were sufficiently funded to achieve their mission. Examples include:

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SAIG-ZA SUBJECT: Tab A (Financial Audit Feedback) to Enclosure 2 (Policy & Training) to Memorandum, Special Interest Item (Sii) inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards .

a. Unfunded Requirement (UFR) lists with one item.

b. Sending end of year money back to Northern Regional Medical Command (NRMC) for FYs 11 - 13.

c. Exceeding the soft fence for equipment for FYs 10 - 12.

UFR LISTS. Budget personnel and various departments told us their unfunded requirements rarely exceeded one item at a time. When a need arose for an unfunded item, they prepared a UFR list for that one item. This lasted until the item was either funded or rescinded. We reviewed documentation that showed one item UFR lists and supported Budget personnel's explanation.

END OF YEAR MONEY. We reviewed resource summary documents for FYs 11 -13 exported from RSBUX. Each year showed money returned to NRMC as excess funds near the end of the year. Here are the amounts:

Year

FY 11 FY 12 FY 13 Total

Amount of Excess Funds Returned to NRMC

$3,320,502 $1,473,600 $803,400

$5,597,502

Equipment Keller ACH had a soft fence on equipment of about $625,000 to 725,000 each year. However, the resource summary showed equipment purchases from $1.5 to $2.6 million a year for FYs 10 - 12. Individuals knowledgeable about expenditures told us KACH intentionally exceeded the equipment fence because they were looking for a place to spend the money.

During sensing sessions, a number of hospital employees told us that supervisors, department I division chiefs or deputies denied requests for staffing and training due to a lack of funding. Personnel perceived a shortage of funding. However, our analysis of Keller finances didn't reveal any impediments to mission based on funding.

SHORTAGE OF FUNDING: Hospital personnel perceived a shortage of money for training even though money was available. Under the umbrella of hospital finances, each department had their own budget consisting of civilian pay, travel, supplies, equipment, registration fees for training and other categories. The budget office told us

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that a phone call from a department or division chief was sufficient to re-allocate money from one area to another within a departmental budget. Supervisors told subordinates that they didn't have money for in-house training aids when departmental budgets had money available for training.

2. DISCUSSION: Sensing sessions often addressed issues with unavailability of funds to support training, obtain training materials or attend training. Nurses from across the hospital discussed how lack of funds prevented buying a packet of training DVDs, inability to buy/produce a policy book, obtain training on how to properly perform equipment sterilization duties. One employee, though lack of training support to be patient safety concern.

In response to these complaints, we reviewed the departmental budgets for Obstetrics (OB), Surgery I Post Anesthesia Care Unit (PACU) and Hospital Administration Services In FY 13, all three departments showed money available for training that was unused at the end of the year. This included money for training registration fees and money for supplies that could purchase training aids, policy books or DVDs. The chart below shows money that was unused at the end of FY 13.

Department or Category FY 13 Unused

Funds

Obstetrics

-Registration fees $1,593

-Supplies $5,023

Surgery/PACU

-Registration fees $0 -Supplies $12,840

Hospital Administration

-Registration fees $550 -Supplies $0

Total Available for Training $20,006

The OB department had a NOELLE infant trainer that acted as a simulator for training OB nurses. However, personnel were not using the equipment because they didn't know how. A phone call to move money from supplies to registration fees could have made money available to bring in trainers for this equipment. Further, there may be




other areas of the hospital that have valuable equipment that no one is currently utilizing.

Surgery I PACU didn't have money budgeted for training registration fees. However, they could have easily moved money from supplies to cover the training. Secondly, they could have made policy books and training aids available to their employees with existing money allocated for supplies. Command should consider allocating funds for departmental training in future years.

Personnel told us that Hospital Services Administration had a library where they provided training tools among other things. However, this department sent back $550 for unused supplies in FY 13. Personnel could have used this money to purchase training materials.

The departmental budgets for these three departments showed money available for training or unused funds that could have provided training or training materials. We recommend that the Commander consider using available funds to provide in-house training aids and to bring trainers into the hospital to teach specific skills.

3. RESOLUTION:

Commander, Keller Army Community Hospital, USMA, consider using available funds to make in-house training materials available to personnel providing patient care.

Commander, Keller Army Community Hospital, USMA, Coordinate for Mobile Training Teams (MTI) to provide proficiency in using critical skills training aids .

Commander, Keller Army Community Hospital, USMA, Consider re-allocating funds from supplies and equipment to staffing and training. Note: The CHRA SME provided the support for the staffing shortages not included in this document.

STANDARDS:

DOD Instruction 6025.13, Medical Quality Assurance (MQA) and Clinical Quality Management in the Military Health System (MHS), incorporated changes from 2 October 2013.

AR 40-68, Clinical Quality Management, 26 February 2004.

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SAIG-ZA SUBJECT: Enclosure 3 (Inspection Objective 2 - Infrastructure and Sanitation) to Memorandum, Special Interest Item (Sii) inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards

INSPECTION OBJECTIVE 2: Assess the adequacy of KACH infrastructure and sanitation.

SUMMARY OF FINDINGS: Keller Army Community Hospital (Building 900) as a facility dates to 1977. As a 1970s structure, it was well suited for inpatient operations but offered limited adaptability for current outpatient treatment requirements. For years, KACH (as real property) fell under management of Installation Management Command and its predecessors with sustainment consuming available resources. In 2010, KACH ownership and management migrated to US Army Medical Command (MEDCOM) who started to focus on long range planning to meet the future needs of the installation to support 21 51 century Army Medical operations. The facility lacked realistic outpatient clinic capabilities , administrative space, and desperately needed replacement of major infrastructure components. Completing such repairs without extended closure was impossible. MEDCOM, Health Facility Planning Agency and US Army Corps of Engineers (USACE) determined that a series of phased projects conducted sequentially best supported all needs. The first hurdle would be a Military Construction (MILCON) Project (#59220) to add approximately 51,000 square feet to KACH, allowing relocation of outpatient clinics and admin space to that new wing. In turn, the vacated space would be renovated I modernized addressing the heating, ventilation, and plumbing problems that plague the facility. These sustainment, renewal , and maintenance (SRM) projects, and phased Major Repair and Renewal (MRR) projects are approved for 2014 - 2015. The stoppage for nearly a year at the 63% completion level and subsequent termination of the prime contractor for default created I highlighted major difficulties for the workforce which was exacerbated by poor strategic communications. As of 15 August 2014, MILCON # 59220 is under contract with a new prime contractor, who commences work in September.

2.1 OBSERVATION (Reference #ID-1406.07): Work stopped on the Keller Army Community Hospital (KACH) military construction (MILCON) project #59220.

ROOTCAUSE: CaniComp~

DISCUSSION: KACH was built prior to the shift in healthcare delivery from inpatient to outpatient treatment modalities. It now lacks the space and departmental relationsh ips necessary to satisfy current and future demands of ambulatory services. As a healthcare platform, KACH no longer presents an environment of care that allows providers to efficiently meet the modern standard of care. Additionally, clinical program changes over time were performed outside of any long term planning framework, resulting in fragmentation of departments.

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To close the performance gap, several essential facility needs were identified. Upgrades related to the in-patient services and the critical outpatient clinics are being addressed by the MILCON project. Other facility work was programmed into a s~ries of SRM projects, and a phased MRR project approved and funded by MEDCOM. KACH gained MEDCOM approval and funding for projects addressing their greatest vulnerabilities - $14 million (M) of recent corrective work is complete, $34M is pending award this FY, and the $64M MRR is programmed for a FY15 start. Figure 1: KACK Addition Concept

Work began in October 2011 but the prime contractor ceased work nearly a year ago at the 62% level of completion . US Army Corps of Engineers (USACE) terminated the prime contractor for default in January 2014. On 15 August 2014, USACE successfully negotiated with the Surety Company to take over the stopped project and restart work in September 2014. MILCON work stoppage significantly · impacted to KACH operations and its personnel. These impacts fell into three categories: 1) Failure to complete addition I alteration left departments that will move into the new wards in substandard space for over a year; 2) Old wards that these departments will vacate are the designated swing space for the wards being renovated with the SRM and MRR projects; work cannot begin until the MILCON space is opened; and 3) The construction site is impeding access to the active part of the facility and parking areas. Figure 2: KACK Addition @ Stoppage

Lack of transparency regarding the status of the MILCON project has interfered with communication. essential to planning future work and has become the source of rumor and employee concerns. There is a chance that if these "domino" projects are significantly postponed, contracting and budgeting restrictions may be further delayed and funding may be lost.

USACE's negotiations with the Surety Company allowed a subcontractor to take over the construction from the defaulted prime contractor and accelerate the schedule to allow beneficial occupancy of the facility by summer 2015. A copy of the project's Critical Milestones and a USACE information on the project is at Tab A to Objective 2. Since other projects' schedules are affected by availability of the facility, and current occupants must vacate the spa.ce for the next start, there is potential funding and schedule risk that bears monitoring.

A final point of discussion concerns the scope of the MRR. With this much construction underway in an active facility, there will be many challenges meeting code and criteria.

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USACE and MEDCOM's Health Facilities Planning Agency (HFPA) are engaged in planning and reviewing the designs for these projects. However, MRR projects are not funded to allow technical review to the depth necessary for a project of this magnitude. MRR projects are also not checked to ensure compliance with UFC 4-510-01 (Design: Medical Military Facil ities) , the DOD medical design and construction standard. This MILCON, SRM and MRR project combination is being provided in lieu of building a new facility. This project is at a critical juncture to assure the project is well planned and executed. USACE should continue working on resolving the stalled MILCON, and, in partnership with HFPA, should ensure these follow-on projects are designed and built IAW the latest codes and criteria described in UFC 4-510-01.

If the MILCON project and the follow-on MRRs are not completed, cadets, cadre, Family members, retirees, and veterans will continue to receive care in ~n outdated environment of care compromised by space constraints and poor functional configuration that creates staff inefficiencies. Healthcare alternatives within the civilian sector are limited, and referring cadets and instructors to the TRI CARE Network will increase lost training and classroom time. KACH's ability to maintain ongoing healthcare operations will be increasingly compromised to the point where it will be difficult for the facility to sustain Joint Commission Accreditation and thereby support the United States Military Academy (USMA) mission.

RECOMMENDATION:

2.1.1 (Reference #10-1406.07.01): CDR USACE report on the resumption of work when it occurs on MILCON project #59220 and provide regular updates to Army leadership.

STANDARDS:

AR 420-1 (Army Facilities Management), 12 February 2008, RAR 24 August 2012, Chapter 4;

AR 40-61 (Medical Logistic Policies), 28 January 2005, paragraphs 8-3c & 8-7j;

Unified Facilities Criteria (UFC) 4-510-01 , 1May2014, Chapter 1;

Supply Bulletin (SB)8-75-11, (Army Medical Department Supply Information), 20 November 2013, Chapter 8;

National Fire Protection Association (NFPA) 101, Life Safety Code, 2012, Chapter 8;

NFPA 99, Health Care Facilities Code, 2012;

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The Joint Commission - Comprehensive Accreditations Manual for Hospital, 15 December 2012, Environment of Care & Life Safety sections.

2.2 OBSERVATION (Reference #10-1406.08.01): There is no command oversight of planned utility shutdowns.

ROOT CAUSE: Don't Know I Won't Comply

DISCUSSION: KACH experiences planned utility shutdowns each month, and the shutdowns affect the utilities in the entire hospital. Our inspection revealed that the utility shutdowns are currently planned and executed by the Chief of the Facilities Management Branch, without detailed coordination with the KACH command team or staff. Planned power outages may be discussed during Emergency Operations Center (EOC) committee meetings, but the minutes of those meetings are not detailed and do not reflect anything more than a passing mention of the impending shutdown. Notification is made to the staff by way of an email message about a week prior to the shutdown.

As these planned outages have been addressed simply as facility events, command involvement before, during, and after the events has historically been limited. The Facilities Management Branch, rather than the EOC, has monitored progress of such events; detailed walk-th roughs have been conducted only in problem areas without a facility-wide closure report. Although not explicitly required by DoDI 6055.1 (DoD Safety and Occupational Health (SOH) Program), August 19, 1998, paragraph E3.2.2 states the "standard for risk management is leadership at the appropriate level of authority making an informed decision to control hazards or accept safety or health risks." Since the event affects the entirety of hospital operations rather than just the facility, the appropriate decision maker should be the Hospital Commander.

We could not document a Comprehensive Risk Assessment for the hospital for the utility outage events. As the events have been viewed as Branch level events, risk assessments were done but at the department level (i.e. Emergency Room, Labor and Delivery, Surgery, Patient) by elements that were more directly affected. None of the risk assessments fully considered the impact of lack of availability of critical medical services to respond to medical events within the community at large. Patient-based risk assessments and inherent risk reduction , control and management functions are not clearly coordinated , which makes the continuity of patient care vulnerable.

RECOMMENDATION:

2.2.1 (Reference #10-1406.08.01): CDR KACH, make planning and executing nonemergency utility shutdowns a deliberate event with command involvement.


SAIG-ZA SUBJECT: Enclosure 3 (Inspection Objective 2 - Infrastructure and Sanitation) to Memorandum, Special Interest Item (Sii) inspection of the Keller Army Community Hospital (KACH)-to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards

STANDARDS:

DoD Instruction 6055.1 (DoD Safety and Occupational Health (SOH) Program), 19 August 1998, Enclosure 3, Paragraph E3.2.2;

AR 40-61 (Medical Logistic Policies), 28 January 2005, Chapter 8.

For Official Use On (FOUO) 3-5 '\ Dissemination is prohibited except s authorized by AR 20-1

SAIG-ZA SUBJECT: Tab A (MRR Timeline) to Enclosure 3 (Inspection Objective 2 - Infrastructure and Sanitation) to Memorandum, Special Interest Item (Sii) inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards

2

• ""ta• WI! 'YY'l"I''., £ I ,,,nm• Keller ACH MILCON - Critical Milestones ~

• Start of Construction ofMRR

September 1 S • Completion of Design phase ofMRR

04.August 15 Troop Ready Date

Furniture Fit-out Complete

• Beneficial Occupancy Delivered

Jll Substantial completion of MILCON

a Start of Construction (no laterthan date)

• Start of MRR Design phase

• Major Repair Renovation (MRR) project award

West Point MIL CON Signed Takeover agreement (revised start)

• ACOE and Surety Company reach agreement on takeover agreement terms

Termination fordefault@63% completion

23 September 11,J" Award of$38M constructioncontradfora 51,218 GSF addition

I• MILCON Milestones e MRR Milestones l (b)(6) & (b)(7)(C) llNCL ASSIFIEDllFOUO Slide 1of2 Asof: 12.Aug 14

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SAIG-ZA SUBJECT: Tab A (MRR Timeline) fo Enclosure 3 (Inspection Objective 2 -Infrastructure and Sanitation) to Memorandum, Special Interest Item (Sii) inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards

Information Paper HQUSACE CEMP-1

21 August 2014

Subject: FY09 DODM Supplemental PN 59220 Keller Anny Community Hospital Clinic Addition, West Point, NY ·

1. Purpose: To provide the construction status of the terminated Keller Hospital Addition contract and address concerns with the timely completion prior to the start of an upcoming SRM project.

2. Project Scope: This is a $38M Medical project to construct a 51,218 GSF clinic addition to the Keller Anny Community Hospital. The addition will house outpatient services to include primary care, orthopedics/podiatry, physical therapy, optometry, ophthalmology, TRICARE services center, staff and administrative support.

3. Status: On 23 September 2011 a construction contract was awarded to Morgan Construction. The Contract is 63% complete and was terminated for default on 10 January 2014 due to non-perfonnance. The project is bonded and after on-going negotiations with the Travelers Casualty and Surety Company of America (Surety), on 7 Jul 14 the parties reached agreement on the tenns of a Takeover Agreement (TOA). The Surety signed the final agreement 13 August 2014, and has hired contractor Gilbane Construction Company. The revised project schedule is as follows: ·

a. Notice To Proceed: 13 August 2014 b. Construction Completion Date: 31 March 2015 c. Troop Ready Date: 4 August 2015

4. Path Forward: USACE New York District oversees resumption of work by Surety.

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Released by: Richard A. Hancock, P.E., SES

Chief, Programs Integration Division Directorate of Military Programs

SAIG-ZA SUBJECT: Enclosure 4 (Inspection Objective 3 - Hiring policies, practices and procedures) to Memorandum, Special Interest Item (Sii) inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards

INSPECTION OBJECTIVE 3: Assess hiring policies, practices and procedures for Keller Army Community Hospital IAW applicable regulatory guidance.

SUMMARY OF FINDINGS: Support provided by the Civilian Human Resource Agency (CHRA) Civilian Personnel Advisory Center (CPAC) servicing West Point in recruitment, classification and training is inadequate to support Keller Army Community Hospital's (KACH) human resources (HR) needs. US Army Medical Command (MEDCOM) provides added support to CHRA by funding four reimbursable positions within the CPAC servicing West Point, yet the positions were not servicing KACH as required by paragraph 13 to MEDCOM I CHRA Support Agreement, # REIM14MEDCOM0001 dated 9 October 2013. CPAC Director servicing West Point, North East (NE) Region CHRA and CHRA Headquarters (CHRA-HQ), failed to apply adequate quality control and oversight of personnel actions, resulting in one regulatory violation and numerous procedural findings. Numerous KACH employees perform dual or triple hatted functions that are not reflected in the individuals' position descriptions (PD). These additional functions detract from the employees' ability to execute the duties described in their PDs and may represent an improper accretion of duties.

3.1 OBSERVATION (Reference #ID-1406.09): The Civilian Personnel Advisory Center (CPAC) servicing West Point is inadequately manned to support client needs in compliance with Office of Personnel Management (OPM) timelines.

DISCUSSION: Timeliness of recruiting actions have historically been inadequate, which is symptomatic of staffing that is inadequately resourced and I or trained to support internal operational requirements and customer demands. As an evaluation tool, DAIG used the CPAC time for the hiring process to occur as one measure of the CPAC staffs ability to support its clients. CHRA advises that although these particular indicators significantly exceed OPM goals, such variance among its CPACs is not unusual. For nearly the last three years, the CPAC servicing West Point is inadequately manned to support client needs in compliance with OPM timelines. CPAC's average fill time for KACH positions failed to meet the recommended OPM 80 day fill time, as shown below.

• FY14 (1st_3rd Qtr): 131.79 days for 23 actions. Human Resource (HR) time was 48.93 days and management (MGMT) time was 72.84 days.

• FY13: 178.41 days for 15 actions. HR time was 70.60 days and MGMT time was 91 .82 days.

• FY12: 117.66 days for 69 actions. HR time was 37.09 and MGMT time was 65.62 days.

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At the time of the inspection, the CPAC servicing West Point consisted of 24 positions (15 Operations and Maintenance, Army (OMA) funded, four reimbursable, five over hires (which includes two temporary positions); this includes six vacancies). Due to the staff shortage within the CPAC servicing West Point, the announcements, certificates and coding of requests for personnel actions (RPA) for positions covered by Title 5 have been outsourced to other NE Region CPACs since November 2013. The CPAC Director servicing West Point has limited full performance staff, and the majority of the staff are trainees. The staffer who was performing recruitment for KACH departed on 11 August 2014. This individual was the sole HR Specialist providing support to KACH prior to the outsourcing .

Discussion concerning non-KACH related HR actions reveals that a majority of the commands at West Point are also having a difficult time recruiting skilled applicants due to the cost of living and budget constraints. The locality adjustment is one of the highest within the Continental US (CONUS). The local competition includes the local Veterans Affairs (VA) hospital, which is located within 30 minutes from West Point. The VA has better incentive programs and salaries to entice skilled applicants. Further, the recent furlough, sequestration and budget constraints, West Point has a difficult time recruiting skilled applicants from outside of the area.

RECOMMENDATIONS:

3.1.1 (Reference #10-1406.09.01): CHRA Director, review staffing and assure the CPAC servicing West Point is adequately manned to support United States Military Academy, KACH , and CHRA West Point HR actions based on the West Point service population .

3.1.2 (Reference #10-1406.09.02): CHRA Director, explore standing up a virtual office to support KACH from another geographic location to be able to obtain a full performance level HR Specialist.

3.1.3 (Reference #10-1406.09.03): CHRA Director, ensure the CPAC servicing West Point places all HR Specialist trainees on the CHRA approved individual development plan (IDP) and that trainees receive appropriate oversight and training from the CHRA West Point CPAC Supervisor.

3.1.4 (Reference #10-1406.09.04): CHRA Director, consider requesting OPM to reevaluate the current locality adjustment rate pertaining to the West Point area to determine sufficiency.

For Official Use Only OUO) 4-2 ~~

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SAIG-ZA SUBJECT: Enclosure 4 (Inspection Objective 3 - Hiring policies, practices and procedures} to Memorandum, Special Interest Item (Sii) inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards

3.2 DEFICIENCY (Reference #ID-1406.10): US Army Medical Command (MEDCOM) reimbursable positions are not being used by CPAC servicing West Point to exclusively support KACH requirements .

ROOT CAUSE: Won't Comply

DISCUSSION: As discussed above, the CPAC servicing West Point is understaffed. MEDCOM and CHRA executed Support Agreement, # REIM14MEDCOM0001 on 9 October 2013. Paragraph 11 to that agreement stipulates that any changes to reimbursable positions must be coordinated between parties. Paragraph 13 stipulates that the positions are full time equivalents. The CHRA NE Region identified the four positions as reimbursable MEDCOM-funded positions. At the time of our inspection, these positions consisted of two supervisory GS-13s, one GS-11 , and one GS-05. However, the two GS-13 supervisory positions are performing other units' actions in addition to KACH actions, and the other two positions are currently vacant. Due to the staff shortage, all KACH actions have been outsourced to other CHRA NE Region CPACs, further bringing into question the appropriateness of the funding of these positions as MEDCOM reimbursable. The CPAC servicing West Point has a high turnover rate and rarely is able to recruit the right skill set required for a full performance HR Specialist; therefore , a majority of positions are trainee positions. Since the GS-13, Supervisor HR Specialist, has been identified as a 100% reimbursable position , that individual is not able to provide the full amount of oversight and training to the trainee positions. The positions at the CPAC servicing West Point are identified as multi function, performing staffing and classification functions for the organizations they service. During the inspection, it was determined that at this time the CPAC lacks the classification knowledge required to assist KACH with classifying positions. The one classifier that is currently on board is a part-time temporary-reemployed annuitant not to exceed 30 September 2014, is funded by another command and priority is given to that command. KACH does not utilize the Workforce Planning Tool (WPT) that tracks and monitors the classification workload.

One of the complaints that KACH presented was the inability to track the status of RPAs submitted. In accordance with CHRA ADM 13-SOP-01, Portal Event Tracker (PET) and Appendix A, the CPAC staff failed to update PET and Portal notes in a timely manner; therefore, KACH had to contact the West Point CPAC staff to obtain the status of RPAs

Based on information obtained during interviews, the CPAC servicing West Point HR personnel systems utilized to perform recruitment are unavailable many times throughout the week. It is unclear if the issue is with the connection to West Point or the HR personnel system itself. The amount of time it takes to prepare one recruitment

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SAIG-ZA SUBJECT: Enclosure 4 (Inspection Objective 3 - Hiring policies, practices and procedures) to Memorandum, Special Interest Item (Sil) inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards

action is overwhelming to most of the staff, and it appears that the junior HR Specialists have insufficient training to perform this function.

There is a perception, continually raised in sensing sessions and interviews of KACH employees, that nepotism is occurring within KACH. However, during the audit, we were unable to find any recruitment actions involving nepotism. Since many of the hiring actions do not include interview panels, and some interviewees hired may be friends with current KACH employees, the misperception of nepotism continues to manifest within KACH. It would be beneficial if the CPAC servicing West Point provided training to supervisors and managers on nepotism and on the means to eliminate such perceptions.

RECOMMENDATION:

3.2.1 (Reference #ID-1406.10.01 ): CHRA Director, ICW reimbursable partners (to include MEDCOM), review reimbursable positions to ensure they are fully funded and fully compliant with support agreements.

STANDARD:

DD Form 1144, MEDCOM - CHRA Support Agreement# REIM14MEDCOM0001, signed by CHRA on 9 October 2013, Paragraphs 11 and 13.

3.3 DEFICIENCY (Reference #ID-1406.11): CPAC servicing West Point, NE Region CHRA, and CH RA-HQ fail to apply adequate quality control and oversight of personnel actions, resulting in one regulatory and numerous procedural findings.

ROOT CAUSE: Don't Know

DISCUSSION:

PROCESS OVERSIGHT: We conducted a quality review on 25 percent of randomlyselected KACH personnel actions for period of 1 January 2010 to 18 July 2014. Due to the limited access to recruitment case files for the 1 January 2010 to 1 March 2012 period, the audit was performed on personnel actions effective between 1 March 2012 to 18 July 2012, accessible via US Army (USA) Staffing. From 1 March 2012 to 18 July 2014, the CPAC servicing West Point processed 85 recruitment actions, of which 22 case files were audited for regulatory and procedural compliance.

For Official Use Onl (FOUO) 4-4 ~ Dissemination is prohibited except a authorized by AR 20-1

SAIG-ZA SUBJECT: Enclosure 4 (Inspection Objective 3 - Hiring policies, practices and procedures) to Memorandum, Special Interest Item (Sii) inspection of the Keller Army Community Hospital (KACH} to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards

All 22 case files were specifically reviewed for evidence of nepotism. As addressed above, the evidence does not support allegations that nepotism was a basis for hiring actions.

Review of these case files revealed one recruitment action that failed to comply with regulatory requirements for veteran preference specified in OPM Delegated Examining Operations Handbook and the 5 Code of Federal Regulation (CFR) Part 332.

Of the 22 case files audited, 14 failed to comply with one or more of the policies and procedures identified in the below guidance. CHRA-HQ received details of individual case "findings" separately for action but personally identifiable information concerns preclude inclusion in this report. Corrective action is partially complete on these cases.

• CHRA Guidance Memorandum (GM) 690-335-13-GM-01 , 13 June 2013;

• CHRA GM USAS-12-CIGM-01 , 6 June 2012;

• CHRA USA Staffing Additional Guidance by Topic, 13 July 2012;

• PPP Handbook, July 2011, Chapter 10 & Chapter 14;

• Strategic Recruitment Discussion (SRO) form, 27 June 2013;

• Office of Personnel Management (OPM) Introduction to the Position Classification Standards, August 2009;

• CHRA USA Staffing Business Rules, 1 April 2013;

• CHRA USAS OnBoarding Manager User Guide, 25 June 2012;

• CHRA USA Staffing Basic Users Guide, 8 March 2013;

• CHRA SOP 355(c)-11-SOP-01, 29 July 2011;

• CHRA ADM 13-SOP-01, Portal Event Tracker (PET) and Appendix A;

• CHRA SOP ADM-13-SOP-02 , Internal Audit & Reporting, 27June 2013;

• OPM Delegated Examining Handbook, May 2007.


SAIG-ZA SUBJECT: Enclosure 4 (Inspection Objective 3 - Hiring policies, practices and procedures) to Memorandum, Special Interest Item (Sii) inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy. and guidance and The Joint Commission standards

KACH also granted 11 non-competitive promotions due to accretion of duties. An audit was conducted on 100% of those actions and determined that three of the actions failed to follow policies and procedures in accordance with CHRA SOP 355(c)-11-SOP-01. Discussion with CPAC staff servicing West Point revealed that the staff did not comply with the directive issued by the CPAC Director to elevate all requests for accretion of duties for Director-level review and consideration.

CHRA OVERSIGHT: In accordance with CHRA SOP ADM-13-SOP-02, Internal Audit & Reporting, dated 27 June 2013, the CHRA NE Region was to perform monthly audits of a sample size of 3-8% of actions processed by all CPACs in their region during the previous month. Due to sequestration, the CPAC Director servicing West Point deferred the requirement to conduct audits for August, September and October 2013. All Regions were to resume conducting internal audits in November 2013. Since November 2013, the CHRA NE Region has submitted only two monthly audits for May and June 2014, which does not comply with CHRA SOP ADM-13-SOP-02 .

RECOMMENDATIONS:

3.3.1 (Reference #ID-1406.11.01 ): CHRA Director, adjudicate improper hiring action concerning veterans preference.

3.3.2 (Reference #ID-1406.11.02): CHRA Director, ensure compliance with CHRA policies and procedures through appropriate oversight and quality review.

STANDARDS:

OPM Delegated Examining Handbook, May 2007;

5 CFR Part 332;

5 CFR Part 511;

CHRA Guidance Memorandum (GM) 690-335-13-GM-01 , 13 June 2013;

CHRA GM USAS-12-CIGM-01 , 6 June 2012;

CHRA USA Staffing Additional Guidance by Topic, 13 July 2012

PPP Handbook, July 2011 , Chapter 10 & Chapter 14;

Strategic Recruitment Discussion (SRO) form, 27 June 2013;



Office of Personnel Management (OPM) Introduction to the Position Classification Standards, August 2009;

CHRA USA Staffing Business Rules, 1April 2013;

CHRA USAS OnBoarding Manager User Guide, 25 June 2012;

CHRA USA Staffing Basic Users Guide, 8 March 2013;

CHRA SOP 355(c)-11 -SOP-01, 29 July 2011 ;

CHRA ADM 13-SOP-01, Portal Event Tracker (PET) and Appendix A;

CHRA SOP ADM-13-SOP-02, Internal Audit & Reporting, 27June 2013.

3.4 DEFICIENCY (Reference #ID-1406.12): Numerous KACH employees perform dual or triple hatted functions that are not included in the individual's position description (PD).

ROOT CAUSE: Can't Comply

DISCUSSION: KACH has had a high turnover rate due to the recent furlough and budget constraints. Due to the reduction in staff, management directed other staff to pick up additional duties to ensure that all functions are being performed within KACH. Some employees have become dual or triple hatted, even when the section is only one deep in the function being performed. Management has failed to update employee's PDs to address the additional duties; therefore, affected employees may not be properly compensated as required by 5 CFR Part 511. At the time of performance appraisal review, supervisors failed to properly review the PD to verify accuracy and need of the function on the current table of distribution and allowances (TOA). The CPAC servicing West Point is not staffed to provide training to customers. Because of this restriction, managers are not receiving training needed to be able to apply sufficient knowledge in classification, performance objectives, staffing and hiring strategies. Due to the lack of training, supervisors are assigning additional duties I functions to employees that may be outside of the employee's current pay grade and occupational series.

As a result of the recent Vice Chief of Staff of the Army review at the Womack Army Medical Center at Fort Bragg, CHRA developed a three day "HR for Supervisors Course." The course objective is to equip both military and civilian supervisors with the knowledge to hire, reward, counsel and discipline their civilian workforce and how to



leverage a partnership with labor unions. Upon request, CHRA will customize this course to support a wider audience of managers and supervisors.

RECOMMENDATIONS:

3.4.1 (Reference #10-1406.12.01 ): Commander, MEDCOM and Superintendent US Military Academy reiterate requirement to all subordinate commands that supervisors and rated personnel conduct a comprehensive review of all Department of the Army Civilians' duties and PDs for accuracy as needed when changes occur and at the time of their annual performance evaluations.

3.4.2 (Reference #10-1406.12.02): Commander, KACH review TDAs to ensure they have identified accurate positions required to perform mission.

3.4.3 (Reference #10-1406.12.03): Director, CHRA consider exporting HR Supervisors course developed for Womack Army Community Hospital to other organizations.

3.4.4 (Reference #10-1406.12.04): Director, CHRA ICW Director, CPAC servicing West Point, provide quarterly training to their customers based on customer needs (classification; staffing; MER; performance objectives; hiring strategies).

STANDARDS:

OPM Delegated Examining Handbook, May 2007;

5 CFR Part 332;

5 CFR Part 511;

CHRA Guidance Memorandum (GM) 690-335-13-GM-01, 13 June 2013;

CHRA GM USAS-12-CIGM-01, 6 June 2012;

CHRA USA Staffing Additional Guidance by Topic, 13 July 2012;

PPP Handbook, July 2011, Chapter 10 & Chapter 14;

Strategic Recruitment Discussion (SRO) form, 27 June 2013;

Office of Personnel Management (OPM) Introduction to the Position Classification Standards, August 2009;



CHRA. USA Staffing Business Rules, 1April 2013;

CHRA USAS OnBoarding Manager User Guide, 25 June 2012;

CHRA USA Staffing Basic Users Guide, 8 March 2013;

CHRA SOP 355(c)-11-SOP-01, 29 July 2011;

CHRA ADM 13-SOP-01, Portal Event Tracker (PET) and Appendix A;

CHRA SOP ADM-13-SOP-02, Internal Audit & Reporting, 27June 2013.


SAIG-ZA SUBJECT: Enclosure 5 (Inspection Objective 4 - Command Climate)) to Memorandum, Special Interest Item (Sii) inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards.

INSPECTION OBJECTIVE 4: Assess the command climate of Keller Army Community Hospital JAW applicable regulatory guidance.

SUMMARY OF FINDINGS:

The inspection team surveyed employees attending sensing sessions with a questionnaire specifically focused on command team involvement, fear of reprisal, employee behavior and administration, in addition to other areas of interest.

The survey consisted of 20 statements with response options from "Strongly Agree" to "Strongly Disagree. " Approximately 27% of the KACH personnel (130) voluntarily took the survey over a four-day period. The results strongly suggest there are issues in some areas that need to be mitigated by KACH leadership. Many respondents were careful to point out their comments were not directed at the current command group but were based on their experience with previous command groups. Many commented that they already saw positive changes under the current leadership. Although the results may be negatively skewed , as it is in the nature of some "volunteers" to have issues to air, the inspection team mitigated this by seeking out hospital employees from other locations in the hospital to obtain a more balanced distribution. The resulting percentages discussed below are based on those who provided a response to the individual statements and should provide some useful insights to KACH leadership.

Analysis of the provided survey responses led to the basic conclusion that communication problems exist within KACH. Informal communication channels have replaced formal communication, which appears to have been inadequate to address the hospital staffs needs. Without formal communications, employees relayed information obtained by hearsay and rumor and in turn communicated questionable information and disinformation. Key issues addressed in such a manner related to the Small Hospital Study and its meaning to KACH, rumors about the closure of KACH and rumors about the stalled hospital addition.

Simultaneous turnover of the chain of command has been the norm since 2007. MEDCOM and HRC routinely reassigned the Commander, Command Sergeant Major, Deputy Commander for Clinical Services (DCCS), Deputy Commander for Nursing (DCN), and Deputy Commander for Administration (DCA) during the early summer replacement cycles and replaced them all within 30-45 days of each other. With a lack of continuity of key leaders and no authorization for a civilian deputy, select long-time employees were perceived as taking advantage of rapid turnover and "running the place."

For Official Use Onl (FOUO) 5-1 '~ Dissemination is prohibited except a authorized by AR 20-1


With a history of sequestration, furloughs, limited I nonexistent employee recognition (bonuses/awards, etc.), and difficulties with hiring, employee satisfaction and confidence have suffered. Employees indicated a lack of faith in fellow employees and the belief that poor performers are not held accountable for their performance and actions. Employees believed that violations of standards are overlooked and that regulations and safety requirements are not always followed or enforced, and some felt they would be "punished" if they "make waves" or raise issues counter to their leadership. Two quotes from the workforce provide insight into some significant challenges the new chain of command must overcome: "Regulations are followed here when convenient," and "Supervisors have historically failed to enforce policies or regulations or to support subordinate supervisors who attempt to do so."

4.1 OBSERVATION {Reference #10-1406.13): Command climate survey data is concerning.

DISCUSSION:

Command Climate: In response to a general Command Climate statement, "The command climate at Keller Army Community Hospital (KACH) is good," a majority (approximately 62%) who took the survey "Disagreed" or "Strongly Disagreed" with the statement. Many commented on the lack of command involvement, low morale, a hostile work environment, nepotism, favoritism, military indifference for civilians and poor communications, which, in itself, was a recurring and prevailing theme in both sensing sessions and interviews.

Although the current command team is actively and aggressively involved in creating a positive climate at KACH, Soldiers and DA civilians still have some less than favorable perceptions about their unit's climate.

Command Involvement: Command involvement was the specific focus of one of the questions. In response to the statement, "Hospital leadership is involved in day-today operations," 46% "Disagreed" or "Strongly Disagreed" with the statement, and 16% chose "Did Not Know" if leadership was involved, a net of over half of the sampled group. Many respondents indicated that their answers were attributed to previous command groups and stated that the current command group was noticeably more engaged. Comments were directed not only at the command group but also at supervisory-level leadership. Perceived indifference of the military towards civilian employees and unseen leaders were common comments,

5-2 ~ For Official Use Only FOUO) Dissemination is prohibited except as authorized by AR 20-1


The inspection team found that the newly arrived command team is actively shaping I establishing a climate at KACH consistent with Army culture. The team found strong evidence of strong leader involvement at KACH with the arrival of the "Big Five". (Commander, CSM, DCCS, DCN and DCA).

Compliance with Standards. Regulations and Procedures: Employees were presented the statement, "My leaders overlook violations of standard(s) in order to achieve short-term organizational results or individual recognition." Nearly half, 48%, chose to "Agree" or "Strongly Agree" with this statement, although there were no specific examples provided by those taking the survey that identified the standards that were overlooked. Along similar lines, 26% chose "Disagree" or "Strongly Disagree," and 30% chose "Don't Know" in response to the statement "Leaders at KACH comply with regulations." This is a reduced percentage, but still a quarter of the surveyed sample believe leaders do not follow regulations. Similarly, for the statement "Safety requirements are enforced at KACH." 25% chose "Disagree" or "Strongly Disagree," while the remaining 75% chose "Agree" or "Strongly Agree."

To an even lesser degree, only 16% "Disagreed" or "Strongly Disagreed" with the statement, "Members of this organization comply with required procedures for medical care," while 23% selected "Don't Know" or "Unobserved." Lastly, to the statement, "Medical incidents requiring investigation are properly referred and adjudicated," only 11 % selected "Disagree" or "Strongly Disagree." "Don't Know" or "Unobserved" were selected by a combined total of 52% of those surveyed, which is not disturbing given that 43% of personnel did not identify themselves as medical professionals and may not be aware of those requirements.

Accountability: There is a prevailing opinion that employees are not held accountable for their performance. In response to the statement, "Employees with poor performance are held accountable for their actions," 66 % chose "Disagree" or "Strongly Disagree," and 16% chose "Don't Know" or "Unobserved" as the response to this question. There is a strong perception that leaders are doing little to correct, counsel or mentor underperforming employees or that those underperforming employees are shown favoritism. Discipline and accountability at KACH seems lacking in the minds of many employees.

Army Values: 43% selected "Disagree" or "Strongly Disagree" in response to the statement, "Leaders, Soldiers and Civilians at KACH embrace the Army values at all times." Although a high standard, the negative response is indicative of a lack of faith in fellow employees to uphold the Army values.



Fear of Retribution: The statement, "I can raise issues to my leaders without fear of retribution," drew a large negative response, with approximately 43% selecting "Disagree" or "Strongly Disagree." There were supporting comments that those who bring attention to issues are ignored, "squelched" or removed from position. One comment heard multiple times is that there was a fear of retribution if an employee submitted a Patient Safety Report. Removal of personnel for raising issues, however, was not found during the inspection. Comments from some who took the survey used the words "toxic" and "depressed" in describing the work environment. In short, there are at least 54 of the 130 personnel surveyeq at KACH that believe they work in an environment where they will be "punished" if they "make waves" or raise issues counter to their leadership.

SUMMARY: The results of this survey of KACH staff perspectives of the hospital and those of patients vary considerably. MEDCOM's Army Provider Level Satisfaction Survey (APLSS) ranks KACH as the #1 hospital in the Army for patient satisfaction since 2010. Satisfaction of surveyed employees does not match that of patients for the past several years.

Clearly, employees are sending mixed messages within the survey and are reflecting personal perspectives about working within the hospital. Their comments speak about lack of compliance with standards, regulations, safety requirements, required medical procedures and requirements for investigating medical incidents. This may be an indication that employees may not understand the differences and the overlap between some standards, regulations, safety requirements, medical procedures and incident reporting . There is much less disagreement with statements pertaining to following standards I procedures when narrowed to actual medical care and medical incident reporting. A smaller element believes patient safety is at risk in comparison to compliance with "general" standards, regulations and other policies. This perspective is not supported by facts, as the inspection team found nothing that indicated patient safety was at risk. Employees may have incorrect information about the various requirements.

Respondents repeatedly stressed that their answers reflect their views towards previous command teams and that the current command team has already made positive changes in the climate. Communication has been a major factor.

Tab A to this Objective provides a detailed analysis of survey responses.

5-4 ~ For Official Use Only FOUO) Dissemination is prohibited except as uthorized by AR 20-1


RECOMMENDATIONS:

4.1.1 Recommendation (Reference #10-1406.13.01): CDR MEDCOM, ensure RMCs conduct Initial I Subsequent Command Inspections. Ensure RMC commanders are apprised of the results of subordinate commanders' command climate surveys IAW AR 600-20.

4. 1.2 Recommendation (Reference #10-1406.13.02): CDR MEDCOM, explore options to avoid simultaneous turnover of hospital command teams, to include deputies, across the MEDCOM in order to provide continuity of leadership for military treatment facilities.

4. 1.3 Recommendation (Reference #ID-1406.13.03): CDR MEDCOM, consider the addition of a civilian executive officer position to the tables of distribution and allowances for hospitals under the MEDCOM to provide civilian leadership and continuity within all MEDCOM hospitals.

4. 1.4 Recommendation (Reference #10-1406.13.04): CDR KACH, review results of previous DEOCS Command Climate Surveys and results of DAIG survey to mitigate the issues identified by the surveys and conduct command climate survey at a later date to be determined to measure changes.

5-5 ~ For Official Use Only (FOUO) Dissemination is prohibited except a authorized by AR 20-1

l I Employee Breakdown

I I Military By Grade ,,,. ----- ·- - --··

90 / •' 80 _i.// __ _

70 j•' I,· ·- -

60 r so - ·· _, ·· 40 -· / .

30 - ·

20 10 ~· ,.· 0 1·-'- ..

Servicemember Federal Civilian

Employee

------------ ----

Af~" -..... _=:!._ __ f

Contractor Other(ex:

Volunteer)

,-

I I : I

! i 12 1' I ,· I 10 I

I ' I I I

I

8

6 .j

I 4 l

~ 2 t . ' al/

A. El

E4/SPC B. E4/CPL- C. E7-E9 E. 01 • 03

E6 L- - · -~---·----------------~

l Surveyed KACH Personnel I

I I I !

I ! I

F. 04-Above

l I I ! I I

I -----i I

:: ~-----_: so ~ ..

I

I 40 -i -------30 1-- ---·

I 20 -i- -

I lO J. -I

0 I

A. Less than 1 year

Time at KACH

B. Between 1 to C. Bet\veen 3 to D. Greater than 5 3 years 5 years years

L___ _ _ ______ _ _ ,

i--

1

Time at KACH I I

•A. Less than lyear

• B. Between 1 to 3 years

-. c. Between 3 to 5 years

• D. Greater than 5 years

I ; L_ _ _J

·-----·---------- --·-·--------

Time in Current Position -.--------· ----- - - - 54

10

! 0 +- ·-·-,--· ·--· ' A. Less than lyear B. Between 1to3 C. Between 3to 5 D. Greaterthan 5

years years years

Time in Current Position I

•A. Less than 1 year

• 8. Between 1 to 3 years

C. Between 3 to S years

• ·o. Greater than 5 years

i L

Summary of KACH Survey ··---·----- -··------ ·------

o~

1. The command climate at Keller Army Community Hospital {KACH) is good.

•A. Stron&~I Aaree B. A8f•• • C. Di>1cru •O. Stronalv Disai:ree

·~. ;

.J . S1"

f j i

.(. ·:•.J:::".

I - _J _______ , _________ -

20% 40% 60% 80% 100%

3. My leader\ overloolt violations of standard{sl in order to achieve short-term orpni:ational results or individual recognition.

• • ',f· ··· · ...... ·~ ... _ •" ..... ...... .. ( ........ .

!1l~i~;~ .... u-.. ~· . '"' ... ... , "" - ,_

.. ..

(i''lo

2. I can raise Issues to my leaders without fear of retribution.

• : •• ,, ... . . -t . . -.,....-~r " ~•Ct ~.., •' l •• o:.. '"" t"rer •I• ·.~ .... • ~-t . (•1 · •• ,..,....,.

'•

J-.

: .. .

I"'' - .. (J'" ....

·-.. ·.:,;:-.. :~~:;,

..... ~ .. ~-~~~-~-

,,a.-.. M4t'" ··

4. Staff are properly utilized at KACH •

W .! 'i l ••h -:-f o1 (,f.:"....,. - 6 -"-tt rr . ,. tK•••t"I,_.. •11 '•lt•Ut!~ f , .. , .. . .. ~ ...

• .. ; ..( ·

z•:- .... it-L•·•;., ao "'

ion ..,

tOO"

Summary of KACH Survey {Continued)

U ·

5. Hospital employees have sufficient resources to accomplish the mission.

• .:.. \ h ~~t.":f~ -~,,.... fl ) ,t:.'I N" .... llh•;t"" • £• 1"'1""o~·t, (1'1\ • i-"J_.

.-_;:;~;. .: ~~ >~~1~ ..... .;_~ ;r

:~· - ~-··

'tt~~· .... ··,·,;::·

{ . .. _t;;;."

1•~" ~,, .. w · .. :t:th

7. Members of this organization comply with required procedures for medical care.

IOU·

•.:.. ~tt •<f• ~:t : ..'..-.• 1....,. a .:.."frr •• f atu~...,. •I• \b·ou t:i',t ....... ,,... I (•htl r•no·,.: :' On<'bu"' M

d "":

.1~.l~ ${l ·Jt·. \-~~~~- :l:f·· ... ·.

10 \, .. ,.,,

.ll"I.

~I .

""~ II()\ JO~h

., .. ~

.,1..

6. KACH staff has sufficient training to accomplish their mission.

•.!. \ffvu!·J. .:. !'.'"""' ~-· p. ..1.ff f"'f"" . .. ........ SJ .... era \h•'l-t:l'r r~\•ilN'

. ~ .

~\;):+ .,.

""· ::*';

···~~· . ·"·'·

,11,• .. ..... . ~ ICO'!.

8. Staffing levels at KACH are sufficient to accomplish the mission.

•:.. ''••tn,~, ~£1f!'t' ll ~"'""" •< r·i~•£J~ •r• \tt·~·~·hni\1t:r ....-

JO". l<J · I.Cl• BO· ·

11>11'1

100-.·

Summary of KACH Survey (Continued)

I)'!.,

It".

9. Safety requirements are enforced at KACH.

• :.... \ ffdl\ (J , ~~-.·~ (t .:..~ , .. •t· Ht~ ... : ,,.,. • ('1 \ ti ,.. .. .i ... (~'"" , ,.

-~ · .. t .. it-•;

... -:.

,;y,~ -~,' ·!, ~~-

···; · ·.' :.:-)~ ;·

· ~. :!'' .

}0~ ~O"- C,q •. 1111·>

11. Leaders, Soldiers and Civilians at KACH embrace the Army values at all times.

a .l. \ft uugi~· Af$n:< Ji A~"" • t M"'• ~·•~ •l} ('Jh t:-ci t·J .- 1~ ·. •~r...,..

.>:r~

:t1fr lll'' · IV• Ml',, 10'¥.

IUI' '··

100-..

10. Hospital employees are qualified to perform their duties.

• .! ~1• t Nh:f\ .::. .-,~ " .:.;, ..... • ( Ol'\4.;Jf'f" •P \ ff Ui;\o~~ ~· t•1 ~· ~ ·- r f1 unlt:u"' •'•

0 "1. ,

II •.

.... l'·

tt l -"'-

.- .. ~ ·. ·

·J':l:} .. . s~~ ~ · ·. ''l:l,

111·. ·lO'~ b\J ·. :<Cf \

12. Required inspections are completed and deficiencies within your area are corrected.

• 4.. ~h llf•.:L .:. ;,•,..... P. .4.,.,..,.. •4 ri.\.•.;•...... •O \ hot\!1·, '"" .. ~ .. ....

/fh. ~O'\. ~ l!tl'•.

lttC'\.,

100'\.

Summary of KACH Survey {Continued) 13. Medical incidents requiring investigation are

properly referred and adjudicated.

• ;. \ t1 .~n ,·i. ·• ·;t rT fl .! i:".trr •f (•iw~N> •I• '•l rran~1 • 0i ·. • r., _ f l••~ lf. 1\1 ~ · 1•n uob \.rf . r-d

... ~

.,;: , .. . ~' : ..

-'.°.' "~~h -· _, -.< 2 . _,-.,_.-, . '"

~; - ,~~;= .W ''Y'J ~l!A- .

. ,;~;:::. '

11.t - ., .. . ,. (,tr. Hi• ··.

15. Contract award procedures at KACH comply with applicable regulations.

l•!I."

• .:.;. 1tfH•U!i • -!. ;tM"" ft .:. ~·tN' . ( (Ji~;.J n- •ft \h ~).flc"f 1• (tt\•f1'..,. f 0u.t~ tt.UC\ ·. ••1tt,l>\f"f ". f"'(I

(I- ,

r. ;

1~. ··.\t

~ '~1·

JO"· •&\.

. fM.11,

""" ¥<I'll. lOQ'\_

14. Civilian hiring procedures at KACH comply with applicable regulations.

· - \hvo~·· · .:. ; .rn- f\ ~ ·!"lr"'f" •f (jp~J t"f"' •f• \tfhl\!-j i ( .. '\. .t ~-,rr f (l t•O ti I U1 .'. tlnut~•. n -!

tr ·

·~ ~j)'io,

10--. 16'•• &-0' '- 8(t\ .

16. Hospital leadership is involved in day-to-day operations.

100-.

• A \h1·1t~ ... .. . '.. ~'J...... ~ .:...~r~ •• Ut\· ~·.1 N" •n '" •Ht~·I; l•h•:-"Jf"'t" f (lcm U 'tt-0 .·. 011.-.•f>\f'f". r-ct

Ho!>.

O". J (K tl1 ' &O'• ll(h. 1~ ..

Summary of KACH Survey (Continued) 17. Employees with poor performance are held

accountable for their actions.

•.:. .... , ... ~t ~ "~ ...... ".:.~ • .,..,...{ ' '• '•"' -:.·1-- •r· \14••0dt"'··.t~'t,... r l• tM•• f1W\ ... / tfuQh'.rf · t"'tj

IJ"•

~ .. ~.

"·

th } .(J \ UI\. !.II"•. ~ .. "

19. Patient care at KACH outweighs financial constraints.

Hi~ .

)(tt.l ·

• .i \ h•*l•~i. ~i'N" ll ~~,~ •f (\h•!..,..,. •f' \bun~"•°'' .. ~f'ilr { (~rt IM .. ~'· Unvl)\rf ' . ...d

i~

It'• Lo,. •tr~ (,O'\:. . ... 100'. -

18. Problems with the facilities and equipment are fixed in a timely manner.

8 .;;,. \boo~·f , .!.if r>t'" ~ .:. i!)IN". ( ( •hfl!'Jt"'t'" .... \t1,-..ngt't0-:'l. "''7,..,,. ( . ltrM1tl1~1 v, l fou.ixf"f ·.nf

1~ lflli.

. ~k~·~:·'·:~:- ..

~ lO' . 4!/' •. uil' ' 80 .. . I Oll•

20. leaders at KACH comply with regulations.

• .; 'f1 0•01-. .:. .• 'l't"t:'" f. :. ~«•'- t~H-('J•'P'•O \tron.~1llt·.,. , .. ,~ t l••-c•1t-.u•1· .... ·.> llth•hl-.1 ··<t:.J

14'

)~:·.,

..... lU ~ 411'•. 6-0' .. llO"'t . Joo·.

The command climate at Keller Army Community Hospital (KACH) is good.

The command climate at Keller Army Community Hospital (KACH) is good.

' 35 -l---

;;;_% 1-------------;;;;;.._ L--~- - --· -··-·-- 7--- -- - ·

45 :----

; -··· ·----- ·····- -

4 0

30 -~1

--·---25 --2 0 · ~ ___ -_--·· - -

15 I

l:~--0 J~---~--,-- .

i L --A~::onRJ1· Agr"" B. Alli""' C Disagr ee D . Str o ngly Disagr ee

I I

__ ..J

The command dimate at Keller Army Community

Hospital (KACH) is good. : .J

45

4J

~s . ----· !.=-· ~ .. -~

30 • :: ....,..,. l q~·-""'-·

'.?.; t; : . ~l..-i · Tt.·!:~·· .. •1Ci_,

ZJ • :>~n"'iftl5t:i!!::I"

• :.~u : 5

I; ~-.-' .. •t:'i~ Jtr:~t~a ~ "J ···· -· -5 - . ··--

~ _ Jt: .

• . 5t'0'11:'\· .i.r-•• 3 .r.,-tt c ~"'i'ff = !<100,+1 !);sor<O

, --··-

I can raise issues to my leaders without fear of retribution.

' I can raise issues to my leaders without fear of retribution.

j SO r ---·· · · · ·· - - -· . ··-· - ··

~~ ·fl --~·=~---_-__ ------~-===--35 - ..

30 ...

25 ~ 20 i

-~---- ·

15 ' 10

5

0

A. Strongly Agree B. A~ee C. Disa2ree

. \--~=-·=-~

O. Strongly Disagree

I can raise issues to my leaders

without fear of retribution.

- :: ~--· =-30 t

20

10 , __

0

A. Strongly Agree B. Agree C. Disagree L___ 0 . Strongly i Disagree

•A. Provider

•B. Nurse (RN/LPN)

IC. Medical Technician

• 0 . Administrator

•f Other

lj( AJI Others

"

" 3t

--

l'::

IC

; -~

My leaders overlook violations of standard(s) in order to achieve short-term organizational results or individual


411"'- - .

-.-

I J. :.tJ ..:-r 11, J.c" ~,., ~ :.91~( c 04.lifr<t c ~~: :;.,-.t\ D 1 .... l l' ~

1'1\'

:,:·

• c•

11)

,!l ~

i c


e .:. · ·:"'·.,, .. f

• !- """- ~ .... :~~~;t ..

!i ·: ""'<''='' ~f! , l'-r' '('•ri

a :: .a.d"''"''t·r~·

· ~ ~·~ .. , ••.tn-"• 1

II . • ... ~ff oir.f"' ........ "' e .. ("11!'9 (. ). .......... e»~,r,o'Slll'~~

SAIG-10 SUBJECT: Tab A (Employee Survey Results) to Enclosure 5 (Inspection Objective 4 -Command Climate)) to Memorandum, Special Interest Item (Sil) inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards.

TAB A (Keller Army Community Hospital - Employee Survey Results)

The survey was taken by 130 KACH employees. The survey consisted of six demographic-type questions and twenty statements. Employees were asked to select the best response from a Likert Scale corresponding to their level of agreement with the statement. The percentages shown on the following charts reflect the results of those who responded to the statement.

1. The command climate at Keller Army Community Hospital !KACH) Is good.

I ---- - "------~------L __ _J_J L~- --~A --- _4°" 60% 10% 100%

- ~. -~Y lead~rs-ov~r~~k-~~la~ons of standardj~) In ---1 order to achieve short·term organizational results

or Individual recognition. a A. ~trongiyAcrtt I S. A&ret C. Oisacree I D. Strongly DISICfff

• ___ _j_ __ lOll 40% 100%

.. ---------- -- --- ------ ------- ·---

48% of those surveyed Agree that their leaders overlook violations of standards In order to achieve short-term

organizational results or individual recognition.

-- --~-.-~~-~~~lse ls~ues to my lead-~rs ____ I wltho,ut fear of retribution. ;

• A. St rontlyAJtl!e B. A&rH • C. Di~1ree • O. SfrontlyOiU&rff

'°" '°" I. _ - ___ '1%_ -----··-··· - - .... -· ·~-·-·-- -100% ___ j

. ·-····--·-· ··- ··· ---· ---··~ ------·---

4. Staff are properly utilized at KACH •

IA.StronglyAcrtt B.A1r,. I C. Du1m 1 0. StrOl\i~ Oi"'ret

---------- --- ---"------'--- ----. ----11)0%

72% Disagree that the staff is used properly.



SAIG-10 SUBJECT: Tab A (Employee Survey Results) to Enclosure 5 (Inspection Objective 4 -Command Climate)) to Memorandum, Special Interest Item (Sii) inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards.

--'·' ·--·-- - - - ' ··1 5. Hospital employees have sufficient ' resources to accomplish the mission.

I A. Stroflify Aefee B. Agree • C. Oisoirtt I 0. StronJly OlsafrH

,,,··

-.. ~:~4~1;

o" 2°"

59% of those surveyed believe that resources are Insufficient, although, Interviews with resource

managers Indicate KACH Is well resourced.

·····--··- ··-·-····· ·-·-··-·· ·--··-···- --·-· ··1 7. Members of this organization comply with

required procedures for medical care. .

•A.SlroolfyAc"" 8.A&rtt I C.~"lf• I D, Strol'!lly~ee t0on·1 ~now/ Unobs1md

.: .... ·.

·,. . . ........... -;.".

' i · I . . I : I :. ___ ·- ---'--·• ·~ ---... - ~- . -L----- - ·--·--1

20% 60% i(X)% ___ I

60% Agree that members of KACH comply with required procedures for medical care. Only 16 %

DisaQree.

·---- ·· - -- , __ _ 6. KACH staff has sufficient training

to accomplish their mission.

U . Stron1ly Agr.. 8.AJr.. • C. Dislcr.. IO. Stroncly Dis-er ..

70% Agree that the staff has adequate training to accomplish the mission.

°" L__

8. Staffing levels at KACH are sufficient to accomplish the mission.

I A.Slro"liyAgree B.Agr• I C.°"'C'H 10.Str""fly Clsoir ..

20% 40% 100% I .--1

Only 30% Agree that staffing levels are sufficient to accomplish the mission. Over half, 69%,

believe KACH Is understaffed. There were mixed comments, however, including that certain

sections were overstaffed and one section, In oartlcular. should be eliminated comoletelv.

5-A-2 ~ For Official Use Onl (FOUO) Dissemination is prohibited except authorized by AR 20-1


I I I

9. Safety requirements are enforced at KACH.

u . Stron,lfy A&ret e. Agret I (. Dlncret Io. Stronc~ Diueret

i °" L. 10% 40% 100%

75% of those surveyed Agree that safety requirements are enforced. 25% Disagreed

------------·-· ·-11. Leaders, Soldiers and Civilians at KACH

embrace the Army values at all times.

9A.SlronciYAgret B.A&ret 1 C.IX11iret 10.Stronili lXllC'et

I

I °" -- ;~· ·- · ~-- -L --!Klll"----- -~L L_. _____ .. ____ . ____ , __ _ _______ .. __

57% of those surveyed Agree that safety requirements are enforced. 25% Disagreed ·

10. Hospital employees are qualified to perform their duties.

IA. SlronJ~ AJr<e I.Air ff I C. Dlsqree 90. StronaJy Oi1•1r,. E. Don't Know

I

. ·:~ ....

i L

I

---.! 61)!1 IOll IOOlli

'---- ·---·--------

69% of respondents Agree that hospital employees are qualified to perfomi their duties. 18% Disagree.

12. Required inspections are completed and defkiencies within your area are corrected.

20% ~ 100% ' ·----- - _ _ ___j

61% of Agree that inspections are conducted as required and deficiencies In their area are corrected.

28% Dlsaaree




---·-· ·· -----· ........ ·-·--·

13. Medical incidents requiring Investigation are properly referred and adjudicated.

• A.Str0111i'f AJrt! · B.Acr"' I C. DISirree I D. Stronrly Di>aer,. E. Don't Know/ UnobsetVed

! _J_

. °" 20% "°" 60% L ___ ___ ___ _

Only 36 % Agree that medical Incidents requiring investigation were properly

addressed. 11 % Disagree but 52% Don't Know I Unobserved.

1

----· ·-------··------·-·---··. ---- ·-1 15. Contract award pr0<:edures at KACH ;

. comply with applicable regulations. I

I L

1.1.Stronc~ A(m B.Agr .. 1C. ~".V•U D. Stron~Oincre• E. Oon'tKnow /Unobstrvrd

100%

·--- -- - ----·---- ··· - -· - -

There Is a fairly evenly split between personnel who Agree and Disagree. The majority of personnel, 66 % Don't Know I Unobserved

whether contract award procedures at KACH

,-----·· --- ...... ---·---,

I

14. Civilian hiring procedures at KACH comply with appficable regulations.

____ _ _j_,_ , --·--·· . -··---- - ·-- ··-··-

i r °" lOOll

L---··--- ---··-

I I

One fourth, Agree that civilian hiring at KACH compiles with appllcable regulations. 36%

Disagree and 40% Don't Know I Unobserved.

16. Hospital leadership Is involved In day-to-day operations.

I I

I I

,._;.:r • . -~: ... + .... :,···

: .. ~!..,~::' .. ·.· -~=~~-~

_ _L _J_ _· _ '. ___ _J L °" ___ 2~- __ '°" _____ '°" ____ &Oll _ _ _ ~~

There is a clear divergence of opinion concerning hospital leadership involvement in

day-to-day operations. 38% Agree with the level of involvement but 46o/o Disagree.

5-A-4 ~ . For Official Use Onl (FOUO)


SAIG-ID SUBJECT: Tab A (Employee Survey Results) to Enclosure 5 (Inspection Objective 4 -Command Climate)) to Memorandum, Special Interest Item (Sii) inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards.

,--··----17. Employees with poor performance are held ,---~;.- ·;roblems ~ith the facilities and equi~~ent --!

. are fixed in a timely manner. :

I I

accountable for their actions.

_L __ ,~' - · __ _J_ __ .i I

:;

·;~~ ;:: ·'

I L °" lll'l _ _ _ '°" ______ 60% __ .'.°" __ ~__J I 0% 20% 10%

L _ ______ ..... ----·

Over half, 66 %, disagree that poor performers are held accountable; 16 % Don't Know I

Unobserved.

19. Patient care at KACH outweighs financial constraints.

I A.luon1~ A111t !.A1r1< I C. lli .. ,, ... 0. Svonily o;..,,,. E. Don't Know I UnobHrved

.. .:;. ..... .... . . . · ... . ~~J1:~~~~~~~:-·:.

·. ~~:~:·.-~. ;:~ ·,

i_~·. 20% 100%

40% Agree that patient at KACH outweighs financial constraints, but 29% Disagree. 31%

Don't Know/Unobserved

Over half, 58%, disagree that problems with facllltles and equipment are fixed In a timely

manner.

20. leaders at KACH comply with regulations.

SA. ! l""'C~ Arff ' 8.A&r" • c. Oi1qr,. • O. ltronc~ C111sr., E. Don't Know /Unobw<od

':"~_ .. =:.·: . ~-:~ . : . •'' : :i.~.~~-'

.. .. -:·; ... :· ~ ..

' ! I

___ _J__J IOOll

43% Agree that leaders at KACH comply with regulations but 26% Disagree. 30% Don't

Know/Unobserved

For Official Use Only FOUO) 5-A-5 ~

Dissemination is prohibited except as. authorized by AR 20-1

SAlG-ZA SUBJECT: Enclosure 6 (Inspection Methodology) to Memorandum, Subject: Special Interest Item (Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards.

INSPECTION METHODOLOGY

1. Objectives. (Reference Enclosure 8-lnspection Directive)

a. Assess the adequacy of Keller Army Community Hospital policy and training with regard to hospital operations.

b. Assess the adequacy of Keller Army Community Hospital infrastructure and sanitation.

c. Assess hiring policies, practices and procedures for Keller Army Community Hospital in accordance with applicable regulatory guidance.

d. Assess the command climate of Keller Army Community Hospital in accordance with applicable regulatory guidance.

2. Inspection Team. A nine-person DAIG inspection team, accompanied by seven subject matter experts (SME) from the Deputy Chief of Staff, G1, Civilian Human Resources Agency (DCS, G1, CHRA), Office of the Surgeon General and Army Medical Command (OTSG/MEDCOM), US Army Corps of Engineers (USAGE) and US Army Audit Agency (AAA).

Team Chief Deputy Team Chief/ Inspector Operations Officer/ Inspector Inspector Inspector Inspector Inspector Inspector Inspector (Physician's Assistant) CPAC Director SME Former Hospital Commander SME Former Deputy Commander for Clinical Services SME Former Deputy Commander for Nursing SME Former Deputy Commander for Administration SME US Army Corps of Engineers- Medical Facilities SME US Army Audit Agency Auditor SME

For Official Use Onl (FOUO)

USAIGA USA I GA USA I GA USAIGA USAIGA USAIGA USAIGA USAIGA USAIGA DCS, G-1, CHRA OTSG OTSG MEDCOM MED COM USACE AAA

6-1 ~ Dissemination is prohibited except a authorized by AR 20-1

SAIG-ZA SUBJECT: Enclosure 6 (Inspection Methodology) to Memorandum, Subject: Special Interest Item (Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards.

3. Scope. The inspection assessed the following :

a. Adequacy of KACH and higher level policies and KACH training programs to assure operations in accordance with (IAW) established policy with regard to hospital operations.

b. Adequacy of KACH infrastructure and sanitation to support hospital operations.

c. Hiring policies, practices and procedures by and in support of KACH to assure operations in accordance with applicable regulatory guidance.

d. Command climate affects on and in support of KACH activites to assure hospital operations and interactions in accordance with applicable regulatory guidance.

4. Methodology.

a. The inspection team conducted a comprehensive assessment of the policies, procedures and oversight mechanisms supporting the hospital. The DAIG team organized one large inspection team to support simultaneous engagements across the entire range of activities of a hospital. Teaming always included one or more IGs and one or more of the SM Es, based on the nature of the interview and the technicality of the function inspected. This concept allowed the inspection team to assess a wider range of activities at the hospital and other locations that supports the hospital. The inspection team visited KACH and those organizations involved in its operations. Interviews included the Command Team, Directors and staff within their directorate. Interviews were done collectively to address general actions and processes and sometimes individually then to address specifics. This process occurred throughout the hospital directorates and included all aspects of hospital operations.

b. Sensing Sessions. The team also conducted sensing session and group interviews of providers, nurses, supervisors and staff contacting 130 personnel. Attendance at sensing sessions was voluntary resulting in contact with -27% of the hospital's personnel. Attendees at all sensing sessions provided written feedback on a command climate survey instrument. The survey consisted of 20 statements with Likert scale response options from "Strongly Agree" to "Strongly Disagree." Participants selected the response corresponding to their level of agreement with the statement. Although the results may be negatively skewed, as it is in the nature of some "volunteers" to have issues to air, the inspection team mitigated this by seeking out hospital employees from other locations in the hospital to obtain a more balanced distribution.


SAIG-ZA SUBJECT: Enclosure 6 (Inspection Methodology) to Memorandum, Subject: Special Interest Item (Sii) Inspection of the Keller Army Community Hospital (KACH) to assess compliance with and implementation of applicable Army and DoD policy and guidance and The Joint Commission standards.

b. Document Review. The inspection team reviewed applicable DoD Policies, DoD Instructions, Army, MEDCOM and CHRA subordinate headquarters directives, regulations, policies, guidance and standing operating procedures. The team reviewed approximately 20 Competency Assessment Folders (CAF) (also known as 6-sided folders) that would be subject to evaluation by The Joint Commission (T JC) during conduct of their triennial surveys. Standards used were identical to T JC's, with KACH's Medical Activity (MEDDAC} Regulation 1-200 Appendix R (KACH's CAF Checklist) as an additional gauge. The team also reviewed policies, regulations and meeting minutes to assess their utility and regulatory compliance.

c. Facility Walk Through Assessment. The inspection team observed operations throughout all areas associated with the medical activities of KACH, the mechanical works, and the warehouse during the inspection to assess conditions, application of and compliance with policy.

5. Locations and agencies visited. US Military Academy at West Point, NY (KACH, US Army Garrison-West Point; Civilian Personnel Activity Center supporting West Point; · and Family Members and DA Civilians being supported by KACH.

6. Findings and observations format.

The inspection team addressed its findings in this report using the following format:

Deficiency/Observation/Positive Note Statement Root Cause(s} Discussion Recommendation( s} Ongoing Actions (if applicable) Standard(s)

7. In the report subjective quantitative terms, such as "few, some, majority and most" apply to describe percentile ranges of personnel interviewed and surveyed. The team used the following thresholds throughout the report:

None Few Some Half

0% 1%- 25% 26%-49% 50%

Majority Most All

For Official Use Onl (FOUO}

51% - 75% 76% - 99% 100%

6-3 ~ Dissemination is prohibited except a authorized by AR 20-1

DEPARTMENT OF THE ARMY UNITED STATES ARMY INSPECTOR GENERAL AGENCY

2530 CRYSTAL DRIVE ARLINGTON VA 22202

SAIG-JD

MEMORANDUM FOR SEE DISTRIBUTION

SUBJECT: Detailed Inspection Plan for the Special Interest Item (Sii) Inspection of Keller Army Community Hospital (KACH), West Point, New York

1. DIRECTIVE: The Inspector General (TIG) signed the Inspection Directive on 24 June 2014 directing an inspection of KACH (see enclosure 1 ).

2. INSPECTION PURPOSE: Conduct a Special Interest Item (Sii) inspection of the Keller Army Community Hospital to assess compliance with and implementation of applicable Army and Department of Defense (DoD) policy and guidance and The Joint Commission standards.

3. OBJECTIVES: The objectives of the inspection are as follows:

a. Assess the adequacy of Keller Army Community Hospital policy and training with regard to hospital operations.

b. Assess the adequacy of Keller Army Community Hospital infrastructure and sanitation.

c. Assess hiring policies, practices and procedures for Keller Army Community Hospital in accordance with applicable regulatory guidance.

d. Assess the command climate of Keller Army Community Hospital In accordance with applicable regulatory guidance.

4. TASK ORGANIZATION:

a. The Inspection team will consist of members of the Department of the Army Inspector General (DAIG) Inspections Division and Subject Matter Experts (SME) from Army Medical Command (MEDCOM); Deputy Chief of Staff (DCS), G-1; the United States Army Corps of Engineers (USAGE); and the United States Army Audit Agency (AAA).

FOR OFFICIAL SE ONLY Dissemination is rohiblted except as Authorized by A 20-1.

This document.~ntains information that is EXEMPT ROM MANDATORY DISCLOSURE u der the FOIA.

SAIG-ID SUBJECT: Detailed Inspection Plan for the Special Interest Item (Sii) Inspection of Army Equities at Joint Bases · .

b. The composition of the DAIG team members is as follows:

Sub ect Matter Ex erts: C L (bJ(6J & (bJ(? )(c J OTSG) COL (bl<6l & (bl<7l(Cl OTSG) COL CbJ(6J & (bJ(7J(CJ (JTF-CAPMED) L TC <bJ(6J & (bJ(7J( MEDCOM) (bl(6l & (bl(7J(Cl (CHRA) (bJ(6J & Cbl(7J(Cl SACE) (b)(6) & (b)(7)(C) (AAA)

5. INSPECTION LOCATlONS AND SCHEDULE: The inspection team will conduct site visits at the following location:

KACH, West Point, NY 20 July - 2 August 2014

6. INSPECTION METHODOLOGY:

a. The inspectlon will be based on information/data gathered through research, document reviews, sensing sessions and interviews With leaders, staff, Soldiers, DA civilians and Family members employed by and receiving medical support from KACH. The Inspection Team will develop findings and recommendations based on the information/data gathered and provide these to the Chief of Staff of the Army In a written report staffed through The Inspector General and the Vice .Chief of Staff of the Army.

b. The Inspection Team will review policies, processes and procedures that govern and support operations at KACH.

c. This Inspection will include but is not limited to: United States Military Academy (USMA) leadership and staff, West Point garrison leadership and staff; KACH Command Team, Staffs and service providers; and Soldiers and Family members receiving medical support from KACH.

d. The DAIG will coordinate with the USMA Inspector General to identify a point of contact {POC) for this inspection. The KACH POC will serve as coordinating agent for

FOR OFFICIAL SE ONLY Dissemination is rohibited except as Authorized by AR 0-1 .

2 This document ~ains information that Is EXEMPT OM MANDATORY DISCLOSURE un er the FOIA.

SAIG-ID SUBJECT: Detailed Inspection Plan for the Special Interest Item (Sii) Inspection of Army Equities at Joint Bases

the DAIG Inspection. As coordinating agent, they will work with the respective DAIG team POC to develop an itinerary for the interview of select personnel. The basic methodology for each inspection visit is as follows:

(1) Interview designated personnel to gather infoITTiation required to assess knowledge of and compliance wrth applicable Army and DoD policy and guidance and The Joint Commission standards.

(2) Conduct Sensing sessions with KACH staff and employees.

(3) Review local policies, plans, programs, SOPs and other related documents not reviewed prior to the inspection.

(4) Interview select personnel regarding Joint Commission, US Army Medical Com~and, and Northern Regional Medical Command Oversight.

7. PERSONNEL FOR INTERVIEWS I SENSING SESSIONS:

a. The DAIG team will conduct Interviews with members of the USMA, garrison, and KACH command and staff and others who are involved in KACH dally operations.

1) USMA leadership and staff

2) West Point Garrison leadership and staff

3) KACH Command Team, staff, and service providers

4) Personnel (as available) who receive medical support from KACH

5) Civilian Personnel Operations Center/Civilian Personnel Advisory.Center leadership and staff

6) American Federation of Government Employees lead

b. Interviews may occur in the interviewee's office or another site that is relatively quiet and free from Interruptions and telephone calls. The coordinating POC should schedule a 60-minute block for each interview (50 minutes for activity plus 10 minutes for relocation).

c. Sensing sessions will be conducted with KACH staff and Soldiers and Family members who receive medical support from KACH. KACH staff sensing sessions will occur separately from Soldier and Family member sensing sessions.

FOR OFFICIA~SE ONLY Dissemination i prohibited except as Authorized by 20-1.

3 This document co~lns Information . that is EXEMPT F M MANDATORY DISCLOSURE und r the FOIA.

SAIG-ID SUBJECT: Detailed Inspection Plan for the Special Interest Item (Sii) Inspection of Army Equities at Joint Bases

d. Sensing Session locations to be selected by the coordinating POC and should be relatively quiet, free from interruptions, and at a neutral site outside of KACH. Sensing sessions should be scheduled in 90 minute blocks.

e. The coordinating agent may adjust the interview and/or sensing session schedule, In coordination with the DAIG team POC.

8. DOCUMENTS/PROGRAMS TO REVIEW: The intent of the document review is to Inspect documents that relate to KACH operations, budget and facilities. Enclosure two is a list of documents required for the Inspection Team's review. The coordinating agent will provide or assist the DAiG team POC In obtaining these documents if required.

9. EVENTS/PROCESSES TO OBSERVE: TBD

10. DAIG TEAM RESOURCES: It is not necessary for the coordinating agent to accompany the DAIG team during the interviews or sensing sessions.

11 . ADMINISTRATIVE SUPPORT REQUIREMENTS: The DAIG team will require the inspected locations to provide office space and Internet access, access to a printer, computer projector (with screen), copier and a secure private office space for up to 16 personnel to conduct daily team meetings.

12. REPORT COMPLETION TIMELINE: The results of this inspection are the basis for a written report that will be distributed to your agency, once approved by the Chief of Staff of the Army. ·This report is expected to be completed and released on or about 22 August 2014.

13. SUSPENSE SUMMARY: The DAIG team POC will coordinate with the USMA Inspector General POC to schedule any required USMA and USAG-West Point interview dates and times. The requested documents listed in enclosure two are due to POC below no later than 16 July 2014.

14. Point of contact is CW 4 (bJ(6 l & (bJ(7J(CJ Ins actions Division. Email address: l(bl<6 l & (bJ(?J(CJ I Phone: COM (bl<5 l & (bl<7J(Cl

Encls as

FOR OFFICIA~SE ONLY Dissemination i prohibited except as Authorized by A 20-1.

(b)(6) & (b )(? )(C)

4

COL,IG Chief, Inspections Division

This document con~ns information that is EXEMPT FR M MANDA TORY DISCLOSURE unde the FOIA.

SAIG-10 SUBJECT: Detailed Inspection Plan for the Special Interest Item (Sii) Inspection of Army Equities at Joint Bases

DISTRIBUTION: The Surgeon General/

Commander, U.S. Army Medical Command

CF: (w/encls} The Inspector General DAIG, Chief, Inspections Division Inspectors General:

MEDCOM, CMD IG NRMC1 CMD IG USMA, CMD IG

FOR OFFICIA~ USE ONLY Dissemination i prohibited except as Authorized by A 20-1.

5 This document con~·ns informatiOn that Is EXEMPT FR M MANDATORY DISCLOSURE unde the FOIA.

.. "'·~

f~1 " . -~

SECRETARY OF THE ARMY WASHINGTON

MEMORANDUM FOR THE INSPECTOR GENERAL

2 ~ JUN 2014

SUBJECT: Complaints of Health and Safety Violations at Keller Anny Community Hospital, United States Military Academy, West Point, New York

1. On June 16, 2014, I received the enclosed anonymous letter from staff members at Keller Army Community Hospital (KACH). enumerating various irregularities and improprieties in the care of patients and the maintenance of hospital facilities that could impact or may have already impacted the health and safety of patients and staff. The letter also contains complaints about improper hiring practices. staffing shortages arising from fiscal constraints and the failure of senior Army medical depanment ieaders to take appropriate action and to address an unhealthy command climate.

2. You are hereby directed to conduct an inspection (to include an employee sensing session) at KACH based on the complaints identified in the enclosure. This directive responds to the complainants' hesitancy to raise their concerns to anyone inside the Army Medical Command.

3. If in the course of this inspection, you identify individuals who may have violated a standard (including whistleblower protections), you are directed to refer those possible violations to the appropriate investigative division within your agency.

4. You are authorized unlimited access to Anny activities, personnel, locations, organizations and documents, as appropriate, to ensure a successful and complete inspection. You are also authorized to task the Anny Staff and subordinate headquaners as an apprQved exception to the HQDA Short Notice Tasking Policy. 03 I 253Z Jan OJ.

S. Provide your written findings and recommendations. along with any investigative referrals to me NL T 60 days from the date of this directive.

Encl as

f\ I... i,q • "'' ~~"-'"'\John M. McHugh 1

Enclosure 2 to Detailed Inspection Plan for Kaller Army Community Hospital (KACH)

Documents required prior to DAIG Interview:

• Command Climate Survey results • Facilities Master Plan • Past Inspection Results1 to include (but not limited to) FY14 OIP and FY14

NRMC Inspection Results • The Joint Commission Inspection findings and corrective action plans • KACH Commander's Blog • KACH Commander's response to anonymous letter, with supporting

documentation • KACH manning documents • MEDDAC Reg 15~1 and applicable appendices • Patient Satisfaction Survey results • Minutes for three latest meetings of each of the following committees:

Environment of Care: Performance Improvement Committee; Executive · Committee of Medical Staff; Patient Safety; and Infection Prevention and Control

• Other committee minutes may be requested upon arrival