Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-01295-232 

Combined Assessment Program
 

Review of the
 

Birmingham VA Medical Center
 

Birmingham, Alabama
 

July 21, 2011
 

Washington, DC 20420
 
Why We Did This Review 

Combined Assessment Program (CAP) reviews are part of the Office of Inspector 

General's (OIG's) efforts to ensure that high quality health care is provided to our 

Nation's veterans. CAP reviews combine the knowledge and skills of the OIG's Offices 

of Healthcare Inspections and Investigations to provide collaborative assessments of 

VA medical facilities on a cyclical basis. The purposes of CAP reviews are to: 

 Evaluate how well VA facilities are accomplishing their missions of providing veterans 

convenient access to high quality medical services. 

 Provide crime awareness briefings to increase employee understanding of the 

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

the OIG. 

In addition to this typical coverage, CAP reviews may examine issues or allegations 

referred by VA employees, patients, Members of Congress, or others. 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Glossary 

AD advance directive 

C&P credentialing and privileging 

CAP Combined Assessment Program 

DBC Disruptive Behavior Committee 

EN enteral nutrition 

EOC environment of care 

facility Birmingham VA Medical Center 

FPPE Focused Professional Practice Evaluation 

FY fiscal year 

HSC Health Systems Council 

IC infection control 

OIG Office of Inspector General 

OR operating room 

OSHA Occupational Safety and Health Administration 

PR peer review 

PRC Peer Review Committee 

QM quality management 

RN registered nurse 

UM utilization management 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Table of Contents
 

Page
 

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

Objectives and Scope................................................................................................ 1
 

Objectives ............................................................................................................... 1
 

Scope...................................................................................................................... 1
 

Reported Accomplishments...................................................................................... 2
 

Results ........................................................................................................................ 2
 

Review Activities With Recommendations .............................................................. 2
 

QM..................................................................................................................... 2
 

Physician C&P................................................................................................... 4
 

Management of Workplace Violence................................................................. 5
 

EOC................................................................................................................... 5
 

Coordination of Care ......................................................................................... 6
 

Review Activities Without Recommendations ......................................................... 6
 

EN Safety .......................................................................................................... 6
 

Medication Management ................................................................................... 7
 

RN Competencies ............................................................................................. 7
 

Comments................................................................................................................... 7
 

Appendixes 

A. Facility Profile .................................................................................................... 8
 

B. Follow-Up on Previous Recommendations........................................................ 9
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 12
 

D. VISN Director Comments .................................................................................. 14
 

E. Facility Director Comments ............................................................................... 15
 

F. OIG Contact and Staff Acknowledgments ......................................................... 19
 

G. Report Distribution ............................................................................................ 20
 

VA OIG Office of Healthcare Inspections 
Executive Summary: Combined Assessment Program 

Review of the Birmingham VA Medical Center, 

Birmingham, AL 

Review Purpose: The purpose was 

to evaluate selected activities, focusing 

on patient care administration and 

quality management (QM), and to 

provide crime awareness training. We 

conducted the review the week of 

May 9, 2011. 

Review Results: The review covered 

eight activities. We made no 

recommendations in the following 

activities: 

 Enteral Nutrition Safety 

 Medication Management 

 Registered Nurse Competencies 

The facility’s reported accomplishments 

were the Operating Room (OR) 

Systems Redesign project that 

increased the number of OR cases and 

the Patient Orientation Program that 

helps veterans new to the VA. 

Recommendations: We made 

recommendations in the following five 

activities: 

QM: Ensure that QM data is consistently 

analyzed and that corrective actions are 

evaluated for effectiveness. Require 

that the designated Utilization 

Management (UM) Ad-Hoc Committee 

reviews UM data and that the facility 

approves the case exemptions for 

Physician UM Advisor review. Ensure 

that peer review data summaries include 

all required elements and that the Peer 

Review Committee monitors closure of 

issues identified or referred for follow-up 

to other venues. 

Physician Credentialing and Privileging: 

Ensure that ongoing Focused 

Professional Practice Evaluation is 

completed within the defined 12-month 

period and that monitoring data is 

maintained in physicians’ profiles. 

Maintain adequate competency data in 

all physicians’ profiles. 

Management of Workplace Violence: 

Ensure all violent incidents involving 

patients are discussed at the Disruptive 

Behavior Committee. 

Environment of Care: Ensure that 

annual bloodborne pathogens training 

and N95 respirator fit testing are 

completed and that compliance is 

monitored. 

Coordination of Care: Ensure that all 

components of written advance directive 

notification are provided to patients and 

that notification is documented in the 

medical record. 

Comments 

The Veterans Integrated Service 

Network and Facility Directors agreed 

with the Combined Assessment 

Program review findings and 

recommendations and provided 

acceptable improvement plans. We will 

follow up on the planned actions until 

they are completed. 

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections i 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Objectives and Scope
 

Objectives
 

Scope
 

CAP reviews are one element of the OIG’s efforts to ensure 

that our Nation’s veterans receive high quality VA health care 

services. The objectives of the CAP review are to: 

	 Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care administration 

and QM. 

	 Provide crime awareness briefings to increase employee 

understanding of the potential for program fraud and the 

requirement to refer suspected criminal activity to the 

OIG. 

We reviewed selected clinical and administrative activities to 

evaluate the effectiveness of patient care administration and 

QM. Patient care administration is the process of planning 

and delivering patient care. QM is the process of monitoring 

the quality of care to identify and correct harmful and 

potentially harmful practices and conditions. 

In performing the review, we inspected selected areas, 

interviewed managers and employees, and reviewed clinical 

and administrative records. The review covered the 

following eight activities: 

	 Coordination of Care 

	 EN Safety 

	 EOC 

	 Management of Workplace Violence 

	 Medication Management 

	 Physician C&P 

	 QM 

	 RN Competencies 

The review covered facility operations for FY 2010 and 

FY 2011 through May 9, 2011, and was done in accordance 

with OIG standard operating procedures for CAP reviews. 

We also followed up on selected recommendations from our 

prior CAP review of the facility (Combined Assessment 

Program Review of the Birmingham VA Medical Center, 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Birmingham, Alabama, Report No. 08-01332-76, 

February 25, 2009). (See Appendix B for further details.) 

The facility had a repeat finding in the emergency/urgent 

care operations area, which appears under physician C&P. 

During this review, we also presented crime awareness 

briefings for 234 employees. These briefings covered 

procedures for reporting suspected criminal activity to the 

OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. 

Reported Accomplishments
 OR Systems 

Redesign 

Patient Orientation 

Program 

In 2008, the facility initiated the OR Systems Redesign 

project to improve the rate of first case on-time starts and to 

reduce the rate of surgical case cancellation. Through 

improved communication, changes in personnel and 

processes, and input from all OR staff, the facility was able to 

increase on-time starts to an average of 80 percent and 

decrease cancellations to an average of 10 percent. 

Additionally, between FYs 2009 and 2010, the facility was 

able to increase the number of OR cases by 9 percent. In 

May 2011, the Deputy Under Secretary for Health for 

Operations and Management selected the project for the 

Systems Redesign Champion Award. 

The purpose of the Patient Orientation Program is to help 

veterans who are new to the VA become more familiar with 

the facility, staff, and services provided. Orientation is 

conducted monthly and usually has an average of 

35 veterans and family members in attendance. It includes a 

tour of the facility, and packets with eligibility and benefits, 

after-hours telephone care, privacy, and prescription refill 

information are provided. 

Results 

Review Activities With Recommendations 

QM	 The purpose of this review was to evaluate whether the 

facility had a comprehensive QM program in accordance with 

applicable requirements and whether senior managers 

actively supported the program’s activities. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

We interviewed senior managers and QM personnel, and we 

evaluated policies, meeting minutes, and other relevant 

documents. We identified the following areas that needed 

improvement. 

Data Analysis. VHA requires that each facility aggregate, 

trend, and analyze data using established goals or 

benchmarks; identify opportunities for improvement; and 

evaluate corrective actions for effectiveness.1 We found that 

the Cardiopulmonary Resuscitation Committee and the UM 

Committee did not consistently analyze data or evaluate 

corrective actions for effectiveness. 

UM. VHA requires an interdisciplinary group to review UM 

data on an ongoing basis and states that facility policy may 

identify cases which can be exempted from referral to a 

Physician UM Advisor.2 We found that the facility did not 

establish the UM Ad-Hoc Committee until March 2011 and 

did not have a process for ongoing review of UM data. In 

addition, the draft of case exemptions for Physician UM 

Advisor review had only been prepared on May 9, 2011, and 

had not yet been approved. 

PR. VHA requires that quarterly PR data summaries, which 

include specific elements, are reviewed by a medical 

executive-level committee and that the PRC have a process 

to monitor closure of issues identified or referred outside of 

the PRC for follow-up.3 We found that quarterly PRC data 

summaries were provided to the QM Council but did not 

include the number of deaths screened for PR, the PR levels 

assigned by initial reviewer, or the number of PR levels 

changed by the PRC. In addition, we found that the PRC did 

not have a process for monitoring closure of issues identified 

or referred for follow-up to other venues. 

Recommendations	 1. We recommended that processes be strengthened to 

ensure that QM data is consistently analyzed and that 

corrective actions are evaluated for effectiveness. 

2. We recommended that the designated UM Ad-Hoc 

Committee reviews UM data and that the facility approves 

the case exemptions for Physician UM Advisor review. 

1 VHA Directive 2009-043, Quality Management System, September 11, 2009. 2 VHA Directive 2010-021, Utilization Management Program, May 14, 2010. 3 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

3. We recommended that PR data summaries include all 

required elements and that the PRC monitor closure of 

issues identified or referred for follow-up to other venues. 

Physician C&P	 The purpose of this review was to determine whether the 

facility had consistent processes for physician C&P that 

complied with applicable requirements. 

We reviewed 10 physicians’ C&P files and profiles and found 

that licenses were current and that primary source 

verification had been obtained. However, we identified the 

following areas that needed improvement. 

FPPE. VHA requires that an FPPE be completed for all 

newly hired physicians and that monitoring data be 

maintained in the physicians’ profiles.4 Facility policy defines 

a 12-month FPPE period. We reviewed the profiles of four 

newly hired physicians; one physician’s FPPE was not due 

for committee review at the time of our visit. We found that 

two of the three completed FPPEs were not completed within 

the defined 12-month period and that the profiles did not 

contain monitoring data for FPPE. 

Ongoing Professional Practice Evaluation. VHA requires 

that data consistent with service-specific competency criteria 

be collected and maintained in each physician’s profile.5 

None of the six applicable physicians’ profiles included in our 

review contained evidence of data for the previous two 

6-month evaluation periods. 

Competency Data. VHA requires that competency data be 

collected and maintained in each physician’s profile. We did 

not find evidence of competency data to support renewal of 

out-of-OR airway management privileges. This is a repeat 

finding from the previous CAP review from the 

emergency/urgent care operations review area. 

Recommendations	 4. We recommended that ongoing FPPE be completed 

within the defined 12-month period and that monitoring data 

be maintained in the physicians’ profiles. 

5. We recommended that adequate competency data be 

maintained in all physicians’ profiles. 

4 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 5 VHA Handbook 1100.19. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Management of 

Workplace 

Violence 

Recommendation 

EOC 

The purpose of this review was to determine whether VHA 

facilities issued and complied with comprehensive policy 

regarding violent incidents and provided required training. 

We reviewed the facility’s policy and training plan. We 

selected three assaults that occurred at the facility within the 

past 2 years, discussed them with managers, and reviewed 

applicable documents. We identified the following area that 

needed improvement. 

Management of Incident. Facility policy requires all violent 

incidents involving patients to be discussed at the DBC. We 

reviewed DBC meeting minutes and did not find discussion 

of an incident where a patient assaulted an employee. 

6. We recommended that processes be strengthened to 

ensure that all violent incidents involving patients are 

discussed at the DBC. 

The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

We inspected the emergency department, primary care (red 

and blue), dental, 3A (gastrointestinal laboratory), 

3K (bronchoscopy), 4 main (surgery), the surgical intensive 

care unit, 5 main (medicine), blind rehabilitation (4th and 

5th floors), palliative care (6th floor), the medical intensive 

care unit, the cardiac catherization laboratory, same 

day/ambulatory surgery, and the OR. The facility maintained 

a generally clean and safe environment. 

OSHA requires construction sites to be secured and oxygen 

tanks to be properly stored. We found the dental 

construction area door unsecured, and we found large, 

portable oxygen tanks in an open hallway outside the 

medical intensive care unit. The facility corrected these 

items while we were onsite; therefore we made no 

recommendations for these findings. However, we identified 

the following conditions that needed improvement. 

IC. OSHA requires that employees with occupational 

exposure risk receive annual training on the OSHA 

Bloodborne Pathogens Rule. We reviewed 34 employee 

training records and found that six employees (18 percent) 

did not have this training documented. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

If facilities use N95 respirators, OSHA requires that 

designated employees are fit tested annually. We reviewed 

38 employee training records and determined that 

14 (37 percent) designated employees did not have the 

required annual fit testing. 

Recommendation	 7. We recommended that annual bloodborne pathogens 

training and N95 respirator fit testing be completed and that 

compliance be monitored. 

Coordination of	 The purpose of this review was to evaluate whether the 

Care facility managed advance care planning and ADs in 

accordance with applicable requirements. 

We reviewed patients’ medical records for evidence of AD 

notification, AD screening, and documentation of advance 

care planning discussions. We also reviewed the facility’s 

policy to determine whether it was consistent with VHA 

policy. We identified the following area that needed 

improvement. 

AD Notification. VHA requires that patients receive written 

notification at each admission to a VHA facility regarding 

their right to accept or refuse medical treatment, to designate 

a Health Care Agent, and to document their treatment 

preferences in an AD.6 As part of notification, patients must 

be informed that VA does not discriminate based on whether 

or not they have an AD. We reviewed the medical records of 

20 patients and found that none of the records contained 

evidence that the patients received notification at the time of 

the most recent inpatient stay. 

Recommendation	 8. We recommended that processes be strengthened to 

ensure that all components of written AD notification are 

provided to patients and that notification is documented in 

the medical record. 

Review Activities Without Recommendations
 

EN Safety	 The purpose of this review was to evaluate whether the 

facility established safe and effective EN procedures and 

practices in accordance with applicable requirements. 

We reviewed policies and documents related to EN and 

patients’ medical records. We inspected areas where EN 

products were stored while conducting the EOC review, and 

6 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

we interviewed key employees. We determined that the 

facility generally met EN safety requirements. We made no 

recommendations. 

Medication	 The purpose of this review was to determine whether the 

Management facility employed safe practices in the preparation, transport, 

and administration of hazardous medications, specifically 

chemotherapy, in accordance with applicable requirements. 

We observed the compounding and transportation of 

chemotherapy medications and the administration of those 

medications in the oncology clinic, and we interviewed 

employees. We determined that the facility safely prepared, 

transported, and administered the medications. We made no 

recommendations. 

RN Competencies	 The purpose of this review was to determine whether the 

facility had an adequate RN competency assessment and 

validation process. 

We reviewed facility policies, interviewed nurse managers, 

and reviewed initial and ongoing competency assessment 

and validation documents for RNs. We determined that the 

facility had established an effective process to ensure that 

RN competencies were assessed and validated and that a 

plan was in place to take action if deficiencies were 

identified. We made no recommendations. 

Comments
 The VISN and Facility Directors agreed with the CAP review findings and 

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 14–18, for the full text of the Directors’ comments.) We will follow up on 

the planned actions until they are completed. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Appendix A 

Facility Profile7 

Type of Organization Tertiary care medical center 

Complexity Level 1b 

VISN 7 

Community Based Outpatient Clinics Anniston, AL 

Bessemer, AL 

Childersburg, AL 

Decatur, AL 

Florence, AL 

Gadsden, AL 

Guntersville, AL 

Huntsville, AL 

Jasper, AL 

Veteran Population in Catchment Area 202,912 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

151 

 Community Living Center/Nursing 

Home Care Unit 

N/A 

 Other N/A 

Medical School Affiliation(s) The University of Alabama at Birmingham 

 Number of Residents 134 

Resources (in millions): 

 Total Medical Care Budget 

FY 2011 (through 

March 2011) 

$351.1 

Prior FY (2010) 

$322.8 

 Medical Care Expenditures $152.7 $322.3 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

1,941 

43,882 

11,735 

1,841 

57,851 

36,431 

o Community Living 

Center/Nursing Home Care Unit 

0 0 

Hospital Discharges 1,879 5,876 

Total Average Daily Census (including all bed 

types) 

112 112 

Cumulative Occupancy Rate (in percent) 76 79 

Outpatient Visits 345,186 639,847 

7 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations 

QM 

Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

1. Complete PRs timely. The PR Subcommittee was N

restructured. A database was 

developed and has been maintained to 

show timely PR completion. 

Y 

2. Ensure submission of quarterly reports of 

PR activities and outcomes to the HSC, as 

required by VHA policy. 

The PRC reports to the QM Council 

who reports to the HSC. After the 

CAP, quarterly minutes were submitted 

to the HSC showing trending and have 

been maintained. 

Y N 

3. Ensure mechanisms are in place to 

adequately evaluate and disclose adverse 

events in accordance with VHA policy. 

The Disclosure of Adverse Events to 

Patients policy was revised to 

restructure the disclosure process. 

Y N 

4. Ensure the Patient Safety Improvement 

Committee formally meets on a regular basis 

and provides an annual report of patient 

safety trends to the HSC. 

The Patient Safety Committee meets 

regularly and provides a summary of 

patient safety trends to the QM Council 

who reports the information to the 

HSC. 

Y N 

Pharmacy Operations and Controlled 

Substances Inspections 

5. Develop a system to assure that all 

controlled substance inspectors have current 

training and certification documentation, as 

required by facility policy. 

All certificates are on file and current. 

The system developed uses calendar 

reminders that prompt Controlled 

Substance Coordinators to verify that 

certificates are on file for all active 

inspectors before the last workday in 

January each year. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

6. Ensure all controlled substances 

discrepancies are reported within the 

timeframe specified in facility policy. 

A policy regarding controlled substance 

discrepancies was modified with a 

timeframe that allows coordination 

between multiple parties. 

Y N 

7. Ensure the physical environment defect 

identified in the clean room is repaired. 

The new access panel was installed in 

the clean room in December 2008. 

Y N 

Coordination of Care 

8. Require medical and nursing staff to 

complete patient transfer and admission 

documentation, as required by VHA policy. 

An electronic transfer form was 

developed to replace the paper form to 

facilitate completion of admission, 

inter-ward, and inter-facility transfers. 

QM monitors compliance. 

Y N 

Medication Management 

9. Ensure IC procedures are enforced when 

administering medications to patients on 

isolation precautions. 

The IC protocol for administering 

medications when a patient is on 

isolation precautions was clarified, 

approved, published, and 

communicated to staff in 

September 2010. Routine 

observations of staff compliance are 

been made during IC and EOC rounds. 

Y N 

Emergency/Urgent Care Operations 

10. Ensure appropriate emergency 

department nurses’ annual competency 

assessments include the skills to perform 

low-volume but high-risk duties and seldom 

used but high-risk medications and 

equipment. 

The emergency department RN 

position-specific competency checklist 

was modified to include skills, 

medications, and equipment that may 

be seldom used but have a high 

potential for causing patient harm. 

Y N 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

11. Ensure provider-specific intubation and 

airway management data are included in the 

reprivileging process, as required by facility 

policy. 

Each provider (other than 

anesthesiologists) who request 

out-of-OR airway management 

privileges must provide proof of at least 

three successful intubations. The proof 

will be either patient notes or 

supervised intubations. 

N Y (see page 4) 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Appendix C 

VHA Satisfaction Surveys
 VHA has identified patient and employee satisfaction scores as significant indicators of 

facility performance. Patients are surveyed monthly. Table 1 below shows facility, 

VISN, and VHA overall inpatient and outpatient satisfaction scores and targets for 

FY 2010. 

Table 1 

FY 2010 

(inpatient target = 64, outpatient target = 56) 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 2 

Inpatient 

Score 

Quarter 3 

Inpatient 

Score 

Quarter 4 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Outpatient 

Score 

Quarter 3 

Outpatient 

Score 

Quarter 4 

Facility 69.8 70.0 75.5 77.5 61.5 57.8 56.6 53.2 

VISN 67.6 63.8 68.3 64.2 52.7 51.7 52.2 52.1 

VHA 63.3 63.9 64.5 63.8 54.7 55.2 54.8 54.4 

Employees are surveyed annually. Figure 1 below shows the facility’s overall employee 

scores for 2008, 2009, and 2010. Since no target scores have been designated for 

employee satisfaction, VISN and national scores are included for comparison. 

0.0 

0.5 

1.0 

1.5 

2.0 

2.5 

3.0 

3.5 

4.0 

4.5 

5.0 

2008 2009 2010 

Facility 

VISN 

National 

VA ALL EMPLOYEE SURVEY 

OVERALL SATISFACTION Figure 1: 

LEVEL OF SATISFACTION 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Hospital Outcome of Care Measures
 Hospital Outcome of Care Measures show what happened after patients with certain 

conditions8 received hospital care. The mortality (or death) rates focus on whether 

patients died within 30 days of their hospitalization. The rates of readmission focus on 

whether patients were hospitalized again within 30 days. Mortality rates and rates of 

readmission show whether a hospital is doing its best to prevent complications, teach 

patients at discharge, and ensure patients make a smooth transition to their home or 

another setting. The hospital mortality rates and rates of readmission are based on 

people who are 65 and older. These comparisons are “adjusted” to take into account 

their age and how sick patients were before they were admitted to the VA facility. 

Table 2 below shows the facility’s Hospital Outcome of Care Measures for 

FYs 2006–2009. 

Table 2 

Mortality Readmission 

Heart Attack Congestive 

Heart 

Failure 

Pneumonia Heart Attack Congestive 

Heart 

Failure 

Pneumonia 

Facility 13.99 11.36 16.54 21.11 19.73 13.43 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

8 Congestive heart failure is a weakening of the heart’s pumping power. With heart failure, your body does not get 

enough oxygen and nutrients to meet its needs. A heart attack (also called acute myocardial infarction) happens 

when blood flow to a section of the heart muscle becomes blocked, and the blood supply is slowed or stopped. If 

the blood flow is not restored in a timely manner, the heart muscle becomes damaged from lack of oxygen. 

Pneumonia is a serious lung infection that fills your lungs with mucus and causes difficulty breathing, fever, cough, 

and fatigue. 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: July 1, 2011
 

From: Director, VA Southeast Network (10N7)
 

Subject: CAP Review of the Birmingham VA Medical Center,
 

Birmingham, AL 

To: Director, Atlanta Office of Healthcare Inspections (54AT) 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

I concur with the findings/recommendations presented in the Birmingham 

VA Medical Center OIG CAP review. Actions taken as a result of these 

findings can be found beginning on the following pages. 

(original signed by:) 

James Clark, MPA 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: June 20, 2011
 

From: Director, Birmingham VA Medical Center (521/00)
 

Subject: CAP Review of the Birmingham VA Medical Center,
 

Birmingham, AL 

To: Director, VA Southeast Network (10N7) 

I concur with the findings/recommendations presented in the Birmingham 

VA Medical Center OIG CAP review. Actions taken as a result of these 

findings can be found beginning on the following page. 

(original signed by:) 

Rica Lewis-Payton, MHA, FACHE 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Comments to Office of Inspector General’s Report
 

The following Director’s comments are submitted in response to the recommendations 

in the Office of Inspector General report: 

OIG Recommendations 

Recommendation 1. We recommended that processes be strengthened to ensure that 

QM data is consistently analyzed and that corrective actions are evaluated for 

effectiveness. 

Concur 

Target date for completion: January 1, 2012 

A Director for Quality Management was identified to fill the position vacancy and was in 

her new position effective June 19, 2011. The new Director for Quality Management, in 

collaboration with all clinical and administrative services, will develop a comprehensive 

Quality Management program to ensure that QM data is consistently analyzed and 

corrective actions are evaluated for effectiveness. 

Recommendation 2. We recommended that the designated UM Ad-Hoc Committee 

reviews UM data and that the facility approves the case exemptions for Physician UM 

Advisor review. 

Concur 

Target date for completion: Approval of case exemptions for Physician UM Advisor 

review: Health Systems Council (Medical Executive Board) agenda item: July, 2011 

Enhancement of UM Ad-Hoc review of UM data: October 1, 2011 

The UM Ad-Hoc Committee was established in March 2011 and will continue to 

enhance its process for reviewing UM data. The Chief, Business Management Service, 

will solicit best practices from other VA facilities with more mature UM Committees and 

utilize these practices as appropriate for this organization’s UM Ad-Hoc Committee. 

The draft of case exemptions for Physician UM Advisor review was prepared on 

May 9, 2011 and will be processed through appropriate approval process(es). 

Recommendation 3. We recommended that PR data summaries include all required 

elements and that the PRC monitor closure of issues identified or referred for follow-up 

to other venues. 

Concur 

Target date for completion: August 1, 2012 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

A Peer Review Data Summary document will be developed and utilized as a means to 

report all required elements that to the Health Systems Council (Medical Executive 

Board). This information will be reported to the Health Systems Council on a quarterly 

basis. In addition, a tracking system will be developed to monitor the closure of issues 

identified or referred for follow up to other venues. This information will be reported on 

a monthly basis to the Peer Review Committee. 

Recommendation 4. We recommended that ongoing FPPE be completed within the 

defined 12-month period and that monitoring data be maintained in the physicians’ 

profiles. 

Concur 

Target date for completion: Implementation of the new approved FPPE process will be 

immediate with ongoing review for compliance by Quality Management. 

Target date for full implementation: May 31, 2012 

A new ongoing FPPE process was established and approved by Health Systems 

Council (Medical Executive Board) on June 23, 2011. 

Recommendation 5. We recommended that adequate competency data be 

maintained in all physicians’ profiles. 

Concur 

Target date for completion: October 1, 2011 

Tools to assist service chiefs and guidelines delineating the process will be developed 

to ensure Ongoing Professional Practice Evaluations (OPPE) and Focused Professional 

Practice Evaluations (FPPE) data are collected and maintained for each independent 

licensed provider. Training on the tools and guidelines will be provided. Quality 

Management will periodically review to ensure compliance with requirements. 

Target date for completion: August 31, 2011 

The Chief, Anesthesia Service will collaborate with all Clinical Service Chiefs and 

providers requesting/requiring “out of OR airway management privileges” to ensure that 

initial and renewal of privileges are documented appropriately. Staff of the 

Credentialing and Privileging Office will ensure that the required documentation is 

maintained and will immediately notify the Chief, Anesthesia Service, the Clinical 

Service Chief, and the provider if there is a failure in the documentation process. 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Recommendation 6. We recommended that processes be strengthened to ensure that 

all violent incidents involving patients are discussed at the DBC. 

Concur 

Target date for completion: October 1, 2011 

Chief, Police Service will send all reports of violence involving patients to the DBC for 

review. A standing agenda item for the DBC will include the review of this report and 

subsequent action(s). Chief, Police Service will revise all applicable policies to reflect 

change in procedure. 

Recommendation 7. We recommended that annual bloodborne pathogens training 

and N95 respirator fit testing be completed and that compliance be monitored. 

Concur 

Target date for completion: Ongoing 

N95 fit testing of the 14 employees identified during the review was completed 

June 2011. A tracking system has been developed to document compliance with fit 

testing. 

Blood borne pathogen training tracking system is currently in place. The Talent 

Management System has an automatic electronic alert to employees indicating the 

need to complete the module. The immediate supervisor also receives the alert and will 

be responsible for ensuring that employees are compliant with annual requirements. 

Recommendation 8. We recommended that processes be strengthened to ensure that 

all components of written AD notification are provided to patients and that notification is 

documented in the medical record. 

Concur 

Target date for completion: October 1, 2011 

A draft Medical Center Memorandum and procedure was developed during the week of 

the OIG CAP Review. Social Work Service, Chaplain Service, Business Management 

Service, and Patient Care Service will collaborate to finalize the Medical Center 

Memorandum and procedure to ensure that all components of a written Advance 

Directive notification are provided to patients and that the notification is documented in 

the medical record. 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact	 For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720 

Contributors	 Susan Zarter, RN, Project Leader 

Audrey Collins-Mack, RN, Team Leader 

Tishanna McCutchen, NP 

Karen Sutton, BS 

Toni Woodard 

Angela Haney, Office of Investigations 

Carl Scott, Office of Investigations 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the Birmingham VA Medical Center, Birmingham, AL 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Southeast Network (10N7) 

Director, Birmingham VA Medical Center (521/00) 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Jeff Sessions, Richard C. Shelby 

U.S. House of Representatives: Spencer Bachus, Terri A. Sewell 

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

VA OIG Office of Healthcare Inspections 20