Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-02080-286 

Combined Assessment Program
 

Review of the
 

Alaska VA Healthcare System
 

Anchorage, Alaska
 

September 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 Alaska VA Healthcare System, Anchorage, AK 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

facility Alaska VA Healthcare System 

FY fiscal year 

OIG Office of Inspector General 

QM quality management 

RN registered nurse 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Alaska VA Healthcare System, Anchorage, AK 

Table of Contents
 

Page 

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

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

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

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

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

Results ........................................................................................................................ 3
 

Review Activity With Recommendation................................................................... 3
 

Physician C&P................................................................................................... 3
 

Review Activities Without Recommendations ......................................................... 3
 

Continuity of Care.............................................................................................. 3
 

Environment of Care.......................................................................................... 3
 

Management of Workplace Violence................................................................. 4
 

QM..................................................................................................................... 4
 

RN Competencies ............................................................................................. 4
 

Comments................................................................................................................... 5
 

Appendixes 

A. Facility Profile .................................................................................................... 6
 

B. Follow-Up on Previous Recommendations........................................................ 7
 

C. VHA Satisfaction Surveys ................................................................................. 8
 

D. VISN Director Comments .................................................................................. 9
 

E. Facility Director Comments ............................................................................... 10
 

F. OIG Contact and Staff Acknowledgments ......................................................... 12
 

G. Report Distribution ............................................................................................ 13
 

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

Review of the Alaska VA Healthcare System, Anchorage, AK 

Review Purpose: The purpose was 

to evaluate selected activities, focusing 

on patient care administration and 

quality management, and to provide 

crime awareness training. We 

conducted the review the week of 

July 18, 2011. 

Review Results: The review covered 

six activities. We made no 

recommendations in the following 

activities: 

 Continuity of Care 

 Environment of Care 

 Management of Workplace Violence 

 Quality Management 

 Registered Nurse Competencies 

The facility’s reported accomplishments 

were the development and 

implementation of a database 

dashboard to measure and monitor the 

facility’s clinical and business 

performance and the joint venture 

utilization management program with 

the 673rd Medical Group hospital. 

Recommendation: We made a 

recommendation for the following 

activity: 

Physician Credentialing and Privileging: 

Ensure that provider privileges are 

facility and setting specific. 

Comments 

The Veterans Integrated Service 

Network and Facility Directors agreed 

with the Combined Assessment 

Program review finding and 

recommendation and provided an 

acceptable improvement plan. We will 

follow up on the planned action until it is 

completed. 

Assistant Inspector General for
 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections i 
CAP Review of the Alaska VA Healthcare System, Anchorage, AK 

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 six activities: 

	 Continuity of Care 

	 Environment of Care 

	 Management of Workplace Violence 

	 Physician C&P 

	 QM 

	 RN Competencies 

The review covered facility operations for FY 2010 and 

FY 2011 through July 21, 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 Alaska VA Healthcare 

System, Anchorage, Alaska, Report No. 08-01459-174, 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Alaska VA Healthcare System, Anchorage, AK 

July 31, 2008). The facility had corrected all findings. (See 

Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings for 75 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 one recommendation for 

improvement. A recommendation pertains to an issue that is 

significant enough to be monitored by the OIG until 

corrective actions are implemented. 

Reported Accomplishments
 Data Dashboard	 The facility developed and implemented a dashboard that 

allows the user to measure and monitor the effectiveness of 

clinical and business performance across the facility. This 

dashboard is an effective tool for monitoring performance 

measures; program compliance; regulatory requirements; 

committee performance; and other process improvement 

activities, such as generating focused reviews. The 

dashboard includes a data timeline, links to source 

references for measuring and monitoring, narrative fields, 

and action plan templates. Analyses (yearly, quarterly, and 

current) are readily available to the user. The dashboard is 

posted on the facility’s intranet site and may be accessed by 

all staff. 

Joint Venture	 Using a systems redesign approach, the facility worked with 

the 673rd Utilization Medical Group hospital to enhance a basic 

utilization management program. Program enhancements Management bridged the continuum of care from admission and discharge 

to the first post-hospital care outpatient visit. 

The program redesign included admission and discharge 

templates. The templates provide specific and concise 

information in the electronic medical record that notify the 

primary care team of the veteran’s inpatient admission, 

discharge plans, post-discharge follow-up calls, and 

post-hospital appointments. Providers can now more easily 

identify potential adverse issues related to medication 

management and discharge follow-up orders. The redesign 

also assists with utilization management and primary care 

roles and responsibilities at discharge and with post-hospital 

instruction clarification. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Alaska VA Healthcare System, Anchorage, AK 

Results 

Review Activity With Recommendation 

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 12 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 area that needed improvement. 

Facility and Setting-Specific Criteria. VHA requires that 

privileges be facility and setting specific.1 Privileges may 

only be granted within the scope of the medical facility 

mission and the setting in which care is delivered. We found 

that 3 of the 12 physicians’ privileges exceeded the scope of 

the medical facility mission and the setting in which the care 

was delivered. For example, two clinic physicians were 

granted privileges to perform endotracheal tube placement 

although that procedure was not performed at the clinic. 

Recommendation	 1. We recommended that provider privileges be facility and 

setting specific. 

Review Activities Without Recommendations
 

Continuity of Care	 The purpose of this review was to determine whether 

communication between community hospitals and the facility 

occurred when facility patients were hospitalized in the 

community. Such communication is essential to continuity of 

care and optimal patient outcomes. In addition, we looked 

for evidence to determine whether primary care providers 

acknowledged and documented patient hospitalizations. 

We reviewed the medical records of 20 facility patients who 

were hospitalized at VA expense in the local community from 

May 2010 through April 2011. We determined that the 

facility generally met requirements. We made no 

recommendations. 

Environment of	 The purpose of this review was to determine whether the 

Care facility maintained a safe and clean health care environment 

in accordance with applicable requirements and whether the 

facility’s domiciliary was in compliance with selected Mental 

1 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Alaska VA Healthcare System, Anchorage, AK 

Management of 

Workplace 

Violence 

QM 

RN Competencies 

Health Residential Rehabilitation Treatment Program 

requirements. 

We inspected the radiology unit, the primary care and dental 

clinics, the pre-operative and recovery areas of same day 

surgery, and the domiciliary. The facility maintained a 

generally clean and safe environment, and the domiciliary 

complied with selected requirements. We made no 

recommendations. 

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. Although 

the facility did not have any incidents of assault in the past 

2 years, it did have a comprehensive workplace violence 

policy. The training plan addressed the required prevention 

and management of disruptive behavior training. We made 

no recommendations. 

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. 

We interviewed senior managers and QM personnel, and we 

evaluated policies, meeting minutes, and other relevant 

documents. The QM program was generally compliant with 

requirements, and senior managers supported the program. 

We made no recommendations. 

The purpose of this review was to determine whether the 

facility had an adequate RN competency assessment and 

validation process. 

We reviewed facility policy, interviewed the Associate 

Director of Patient/Nursing Services, 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 actions were taken when 

deficiencies were identified. We made no recommendations. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Alaska VA Healthcare System, Anchorage, AK 

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

recommendation and provided an acceptable improvement plan. (See Appendixes D 

and E, pages 9–11, for the full text of the Directors’ comments.) We will follow up on 

the planned action until it is completed. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Alaska VA Healthcare System, Anchorage, AK 

Appendix A 

Facility Profile2 

Type of Organization Ambulatory care facility 

Complexity Level 3 

VISN 20 

Community Based Outpatient Clinics Fairbanks, AK 

Kenai, AK 

Mat–Su, AK 

Veteran Population in Catchment Area 77,022 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

50 Domiciliary Residential Rehabilitation 

Treatment Program beds 

 Community Living Center/Nursing 

Home Care Unit 

0 

 Other 0 

Medical School Affiliation(s) None 

 Number of Residents 0 

Resources (in millions): 

 Total Medical Care Budget 

FY 2011 (through 

March 2011) 

$138.6 

Prior FY (2010) 

$146.2 

 Medical Care Expenditures $95.5 $150.6 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

546 

13,750 

N/A 

529 

15,455 

N/A 

o Community Living 

Center/Nursing Home Care Unit 

N/A N/A 

Hospital Discharges N/A N/A 

Total Average Daily Census (including all bed 

types) 

36.6 39.3 

Cumulative Occupancy Rate (in percent) 85.45 81.45 

Outpatient Visits 82,684 158,249 

2 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Alaska VA Healthcare System, Anchorage, AK 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Ensure that provider profiles consistently 

include adequate data to review 

performance and competence. 

Provider profiles have been developed 

that include criteria for monitoring 

adequate data for consistent review of 

performance and competence. 

Compliance for Ongoing Professional 

Practice Evaluation is monitored and 

reported through the Executive 

Committee of the Medical Staff. 

Y N 

Environment of Care 

2. Ensure that responsible managers conduct 

the required missing patient drills and that the 

new missing patient policy complies with VHA 

requirements. 

A policy was developed after the CAP 

review and has been implemented and 

maintained. 

Y N 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Alaska VA Healthcare System, Anchorage, AK 

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 

quarters 3 and 4 of FY 2010 and quarters 1 and 2 of FY 2011. 

Table 1 

FY 2010 FY 2011 

Inpatient Score 

Quarters 3–4 

Outpatient 

Score 

Quarter 3 

Outpatient 

Score 

Quarter 4 

Inpatient Score 

Quarters 1–2 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Facility * 50.8 54.9 * 55.0 43.8 

VISN 67.2 50.0 50.1 61.6 49.4 47.6 

VHA 64.1 54.8 54.4 63.9 55.9 55.3 

* Facility does not provide inpatient care. 

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

scores for 2009, 2010, and 2011. Because 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 

2009 2010 2011 

Facility 

VISN 

National 

VA ALL EMPLOYEE SURVEY 

OVERALL SATISFACTION Figure 1: 

LEVEL OF SATISFACTION 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Alaska VA Healthcare System, Anchorage, AK 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date: August 26, 2011
 

From: Director, Northwest Network (10N20)
 

Subject: CAP Review of the Alaska VA Healthcare System,
 

Anchorage, AK 

To:	 Director, Denver Office of Healthcare Inspections (54DV) 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

Thank you for the opportunity to provide a status report on follow-up to the
 

findings from the Combined Assessment Program Review of the Alaska
 

VA Healthcare System, Anchorage, AK.
 

Attached please find the facility concurrence and response to the finding
 

from the review.
 

If you have additional questions or need further information, please
 

contact Susan Gilbert, Survey Coordinator, VISN 20 at (360) 567-4678.
 

(original signed by:) 

Susan Pendergrass, DrPH 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Alaska VA Healthcare System, Anchorage, AK 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: September 1, 2011 

From: Director, Alaska VA Healthcare System (463/00) 

Subject: CAP Review of 

Anchorage, AK 

the Alaska VA Healthcare System, 

To: Director, Northwest Network (10N20) 

Thank you for the thorough Combined Assessment Program Review of 

the Alaska VA Healthcare System, Anchorage, AK. 

We have reviewed and concur with the finding. Please see attached 

response. 

If you have any questions, please contact John Dee, Chief, Quality 

Management, at (907) 257-5445. 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Alaska VA Healthcare System, Anchorage, AK 

Comments to Office of Inspector General’s Report
 

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

the Office of Inspector General report: 

OIG Recommendation 

Recommendation 1. We recommended that provider privileges be facility and setting 

specific. 

Concur 

Target date for completion: August 31, 2011 

1. The header on all privilege delineation forms will be changed to Alaska VA 

Healthcare System, effective immediately. CBOCs will be lined out of the header on all 

active privilege forms. All new and renewed forms will have the new header. 

2. The Medical Executive Board (MEB) has approved revision of all privilege delineation 

forms so that they clearly indicate the settings (location) where each core privilege may 

be performed. All privilege forms will be updated as needed by August 31, 2011. 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Alaska VA Healthcare System, Anchorage, AK 

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 Virginia Solana, RN, MA, Project Leader 

Ann Ver Linden, RN, MBA, Team Leader 

M. Davidson Martin, Office of Investigations 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Alaska VA Healthcare System, Anchorage, AK 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Northwest Network (10N20) 

Director, Alaska VA Healthcare System (463/00) 

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: Mark Begich, Lisa Murkowski 

U.S. House of Representatives: Don Young 

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

VA OIG Office of Healthcare Inspections 13