Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-01107-243 

Combined Assessment Program
 

Review of the
 

VA Pittsburgh Healthcare System
 

Pittsburgh, Pennsylvania
 

August 2, 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 VA Pittsburgh Healthcare System, Pittsburgh, PA 

Glossary 

AD advance directive 

BSC bio-safety cabinet 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CSC Customer Service Committee 

ED emergency department 

EMR electronic medical record 

EN enteral nutrition 

EOC environment of care 

facility VA Pittsburgh Healthcare System 

FY fiscal year 

JC Joint Commission 

OIG Office of Inspector General 

PR peer review 

PUMA Physician Utilization Management Advisor 

QM quality management 

RN registered nurse 

SDS same day surgery 

UM utilization management 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

Table of Contents
 

Page
 

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

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

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

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

Reported Accomplishment........................................................................................ 2
 

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

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

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

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

EOC................................................................................................................... 6
 

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

Coordination of Care ......................................................................................... 7
 

Review Activities Without Recommendations ......................................................... 8
 

EN Safety .......................................................................................................... 8
 

Management of Workplace Violence................................................................. 8
 

Physician C&P................................................................................................... 8
 

Comments................................................................................................................... 9
 

Appendixes 

A. Facility Profile .................................................................................................... 10
 

B. Follow-Up on Previous Recommendations........................................................ 11
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 13
 

D. VISN Director Comments .................................................................................. 15
 

E. Facility Director Comments ............................................................................... 16
 

F. OIG Contact and Staff Acknowledgments ......................................................... 23
 

G. Report Distribution ............................................................................................ 24
 

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

Review of the VA Pittsburgh Healthcare System, 

Pittsburgh, PA 

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 

April 11, 2011. 

Review Results: The review covered 

eight activities. We made no 

recommendations in the following 

activities: 

	 Enteral Nutrition Safety 

	 Management of Workplace Violence 

	 Physician Credentialing and 

Privileging 

The facility’s reported accomplishment 

was the mental health unit’s sensory 

modulation room, which reduced 

assaults by decreasing external 

stimulation for aggressive patients. 

Recommendations: We made 

recommendations in the following five 

activities: 

Quality Management: Ensure that: 

	 Peer Review (PR) Committee meeting 

minutes document actions taken for 

Level 2 and 3 PRs. 

	 The Director’s approval is requested 

and obtained for PR extensions. 

	 Cases that do not meet utilization 

management (UM) criteria are referred 

to a Physician UM Advisor. 

	 UM data are reported. 

	 Providers assess and document all 

required elements prior to performing 

moderate sedation. 

	 Resuscitation episodes are analyzed 

and benchmarked. 

 All required medical record review 

components are collected, analyzed, 

and reported. 

 Patient complaint data are trended and 

analyzed by the Customer Service 

Committee and that minutes are 

reviewed by a senior-level committee. 

Registered Nurse Competencies: 

Document competencies, actions taken 

when deficiencies are identified, and 

competency evaluator qualifications. 

Specify competency validation methods. 

Environment of Care: Complete and 

monitor N95 respirator fit testing. 

Ensure privacy for women patients in 

the same day surgery unit. 

Medication Management: Ensure staff 

safely compound and handle hazardous 

drugs. 

Coordination of Care: Strengthen 

advance directive notification and 

documentation processes. 

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 VA Pittsburgh Healthcare System, Pittsburgh, PA 

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 April 11, 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 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

Assessment Program Review of the VA Pittsburgh 

Healthcare System, Pittsburgh, Pennsylvania, Report 

No. 08-02871-52, January 13, 2009). (See Appendix B for 

further details.) The facility had a repeat finding in the area 

of patient complaint analysis and reporting. 

During this review, we also presented crime awareness 

briefings for 350 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 Accomplishment
 Sensory 

Modulation Room 

To address escalating and aggressive patient behavior while 

respecting patient privacy, a sensory modulation room was 

designed and implemented on a mental health unit. The 

room was based on the concept of daycare timeout stations. 

The design decreases external stimuli and promotes 

relaxation using aromatherapy, massage pillows, weighted 

blankets, clay, squeeze balls, reading materials, and other 

audio-visual relaxation items. Following implementation of 

the sensory modulation room, the assault rate on the mental 

health unit dropped dramatically (by 50 percent). 

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. 

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. 

PR. VHA requires that the PR Committee receive feedback 

regarding actions taken for Level 2 or 3 PRs.1 We reviewed 

PR Committee meeting minutes and did not find evidence of 

1 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

this feedback. VHA also requires that extensions be 

requested from and approved by the facility Director when 

PR completion will exceed 120 days. We did not find 

extension requests or approvals for the four PRs that 

required more than 120 days to complete. 

UM. VHA requires that facilities have a designated and 

trained PUMA who reviews all cases not meeting UM 

criteria.2 We did not find evidence that the facility had 

designated and trained a PUMA to review cases. In addition, 

VISN 4 requires that facilities analyze and report selected 

UM data; however, we found that the facility did not report all 

the required UM data. For example, the facility did not 

include analysis of the acute bed day of care rate and the 

number of, and reasons for, diversion. 

Moderate Sedation. VHA requires providers to assess 

patients and document assessment findings prior to 

performing moderate sedation.

3 We did not find 

documented evidence that providers assessed patients for 

all required elements. For example, we did not find 

documentation of airway assessment in 4 of the 10 EMRs 

reviewed. 

Review of Resuscitation and Its Outcomes. VHA requires 

facilities to track, trend, analyze, and benchmark for specific 

areas of resuscitation review.4 We found that not all required 

resuscitation data had been reported and that data was not 

benchmarked. For example, data was not reported for 

erroneous or deficient resuscitation-related procedures and 

unavailable or malfunctioning equipment. 

Medical Record Review. VHA requires facilities to conduct 

EMR reviews that include specific components.5 We found 

that EMR quality reviews did not include all of the required 

components. For example, the facility did not gather, 

analyze, and report data on discharge summaries, operative 

reports, and history and physical notes. 

Patient Complaints. VHA policy requires that patient 

complaint and patient satisfaction data be collected, trended, 

and analyzed and included, along with other quality 

2 VHA Directive 2010-021, Utilization Management Program, May 14, 2010.
 3 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2006.
 4 VHA Directive 2008-063, Oversight and Monitoring of Cardiopulmonary Resuscitative Events and Facility
 

Cardiopulmonary Resuscitation Committees, October 17, 2008.
 5 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006.
 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

improvement data, for discussion in the appropriate facility 

committees and forums.6 We found that CSC meeting 

minutes did not include trending and analyses of patient 

complaint data and were not reviewed by a senior-level 

committee. This was a repeat finding from the previous CAP 

review. 

Recommendations	 1. We recommended that processes be strengthened to 

ensure that PR Committee meeting minutes document 

actions taken for Level 2 and 3 PRs. 

2. We recommended that processes be strengthened to 

ensure that all PRs that exceed 120 days have extensions 

requested from and approved by the facility Director. 

3. We recommended that the facility designate and train a 

PUMA and strengthen processes to ensure that cases that 

do not meet UM criteria are referred to the PUMA. 

4. We recommended that processes be strengthened to 

ensure that all required UM data elements are reported. 

5. We recommended that processes be strengthened to 

ensure that providers assess and document all required 

elements prior to performing moderate sedation. 

6. We recommended that processes be strengthened to 

ensure that data related to resuscitation episodes are 

analyzed and benchmarked. 

7. We recommended that processes be strengthened to 

ensure that all required medical record review components 

are collected, analyzed, and reported. 

8. We recommended that patient complaint data be 

trended and analyzed by the CSC and that CSC meeting 

minutes be reviewed by a senior-level committee. 

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 

6 VHA Handbook 1003.4, VHA Patient Advocacy Program, September 2, 2005. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

and validation documents for 12 RNs. We identified the 

following areas that needed improvement. 

Facility Competency Validation Process. The JC requires 

that clinical staff are deemed competent to perform their job 

responsibilities and that the facility takes action when staff 

competency does not meet expectations. A competency 

validation policy or process is required for staff who provide 

patient care, treatment, or services. Assessment and 

validation of competencies should be done when the RN is 

hired and then at least every 3 years. We found that the 

facility did not follow their competency validation policy. 

Core and unit/position-specific competencies were identified, 

but the required documentation of completed competencies 

was not consistently available. Additionally, although the 

facility had a process to take action to correct identified 

deficiencies, we found inconsistent evidence that actions 

were taken. 

Competency Validation Documentation. The JC requires 

that nursing personnel are competent to function in their 

assignments. Core competencies, such as medication 

administration, are skills required for all RNs. Unit/position 

competencies are specific to a particular area of patient care, 

such as an intensive care unit. None of the 12 RN 

competency folders contained sufficient evidence that core 

and unit/position-specific competencies had been validated. 

All of the folders had incomplete or missing validation of 

documentation or outdated forms. 

Competency Validation Methods. The JC requires facilities 

to specify the assessment methods used (such as test 

taking, demonstration, or simulation) to determine an 

individual’s competency in required skills. We found that 

validation methods for some competencies were not 

specified for the skill being assessed and validated. 

Competency Validation by Qualified Individuals. The JC 

requires that competency is assessed and validated by an 

individual with the appropriate education, experience, or 

knowledge related to the skills being reviewed. Facility 

policy did not specify the qualifications required for 

individuals who perform competency assessment and 

validation. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

Recommendations 

EOC
 

9. We recommended that the established policy for 

documentation of completed competencies be followed and 

that responsible staff consistently document actions taken 

when competency deficiencies are identified. 

10. We recommended that processes be strengthened to 

ensure that competency validation documentation is 

complete and current. 

11. We recommended that core and unit/position-specific 

competency validation documentation specify the methods 

used to assess and validate competency. 

12. We recommended that managers specify the 

qualifications required for individuals who perform RN 

competency assessment and validation. 

The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

At the University Drive division, we inspected medical (6W), 

surgical (4W), and medical intensive care units; the podiatry 

clinic; the ear, nose, and throat clinic; the SDS unit; and the 

ED. At the Highland Drive division, we inspected the locked 

mental health (1–3W) unit. At the Heinz division, we 

inspected the palliative care (3A) and community living 

center (3B) units. We identified the following conditions that 

needed improvement. 

N95 Respirator Fit Testing. If facilities use N95 respirators, 

the Occupational Safety and Health Administration requires 

that designated employees are fit tested annually. We 

reviewed 15 employee training records and determined that 

6 designated employees did not have the required annual fit 

testing. 

SDS Unit Privacy. VHA requires that women patients 

wearing examination gowns have access to gender-specific 

restrooms without going through public areas.7 All SDS 

patients were required to cross a busy hallway to access the 

gender-specific restrooms and changing areas. Therefore, 

patient privacy was not being maintained. 

7 VHA Handbook 1330.01, Health Care Services for Women Veterans, May 21, 2010. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

Recommendations	 13. We recommended that N95 respirator fit testing be 

completed annually and that compliance be monitored. 

14. We recommended that the facility ensure privacy for 

women patients in the SDS unit. 

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 identified the following area that needed 

improvement. 

Safe Work Practices. The American Society of 

Health-System Pharmacists requires safe handling of 

hazardous drugs to minimize contamination and ensure staff 

and patient safety. All items needed for compounding drugs 

must be gathered before beginning work, and the BSC 

should not be exited once compounding has begun. 

However, if it is necessary to exit and re-enter the BSC, 

contaminated outer gloves must be removed before touching 

supplies, and new outer gloves must be donned before 

re-entering the BSC. We observed a pharmacy staff 

member exit the BSC without removing outer gloves, gather 

additional supplies, and re-enter the BSC without donning 

new outer gloves. 

Recommendation	 15. We recommended that pharmacy staff who compound 

chemotherapy medications remove outer gloves before 

exiting the BSC and don new outer gloves before re-entering 

the BSC. 

Coordination of 

Care 

The purpose of this review was to evaluate whether the 

facility managed advance care planning and ADs in 

accordance with applicable requirements. 

We reviewed patients’ EMRs 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 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

their right to accept or refuse medical treatment, to designate 

a Health Care Agent, and to document their treatment 

preferences in an AD.8 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 EMRs of 

20 patients and found that none of the EMRs contained 

evidence of all components of written notification. 

Recommendation	 16. 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 EMR. 

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’ EMRs. While conducting the EOC review, we also 

inspected areas where EN products were stored, and we 

interviewed key employees. We determined that the facility 

generally met EN safety requirements. We made no 

recommendations. 

Management of	 The purpose of this review was to determine whether VHA 

Workplace facilities issued and complied with comprehensive policy 

regarding violent incidents and provided required training. Violence 

We reviewed the facility’s policy and training plan. 

Additionally, we selected three assaults that occurred at the 

facility within the past 2 years, discussed them with 

managers, and reviewed applicable documents. The facility 

had a comprehensive workplace violence policy and 

managed the assaults in accordance with policy. The 

training plan addressed the required prevention and 

management of disruptive behavior training. We made no 

recommendations. 

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 15 C&P files and profiles and meeting minutes 

during which discussions about the physicians took place. 

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

VA OIG Office of Healthcare Inspections 8 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

We determined that the facility had implemented a consistent 

C&P process that met current requirements. 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 15–22, for the full text of the Directors’ comments.) We consider 

Recommendations 2, 14, 15, and 16 closed. We will follow up on the planned actions 

for the open recommendations until they are completed. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

Appendix A 

Facility Profile9 

Type of Organization Tertiary care medical center 

Complexity Level 1a 

VISN 4 

Community Based Outpatient Clinics Monaca, PA 

St. Clairsville, OH 

Uniontown, PA 

Washington, PA 

Greensburg, PA 

Veteran Population in Catchment Area 433,274 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

237 

 Community Living Center/Nursing 

Home Care Unit 

262 

 Other 84 

Medical School Affiliation(s) University of Pittsburgh Medical School, 

Graduate Medical Education 

 Number of Residents 950 

Resources (in millions): 

Current FY (through 

January 2011) 

Prior FY (2010) 

 Total Medical Care Budget $436.6 $422.2 

 Medical Care Expenditures $289.8 $422.0 

Total Medical Care Full-Time Employee 

Equivalents 

2,295.5 2,258.2 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

36,912 (through 

December 2010) 

60,141 

o Acute Care 13,844 42,112 

o Community Living 

Center/Nursing Home Care Unit 

25,553 74,788 

Hospital Discharges 2,955 8,741 

Total Average Daily Census (including all bed 

types) 

474.53 475.09 

Cumulative Occupancy Rate (in percent) 81.4 81.5 

Outpatient Visits 141,831 (through 

December 2010) 

561,997 

9 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

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 CSC minutes are reviewed 

by a senior-level committee and that patient 

satisfaction data is tracked, trended, and 

analyzed. 

Quarterly round table discussions with 

leadership and service line vice 

presidents were implemented, and 

veterans were invited to strategic 

planning sessions. Satisfaction data is 

presented at the Executive Leadership 

Board. The Veteran Service Council 

was disbanded. 

N Y (see pages 3–4) 

2. Ensure that a policy is developed 

regarding the copying and pasting of text in 

the EMR and that a process to monitor 

copying and pasting in the EMR is 

implemented. 

Facility policy was developed. 

Monitoring criteria for copying and 

pasting were established, and reports 

are provided to the continuous 

readiness team. 

Y N 

EOC 

3. Ensure all Environmental Management 

Service employees receive the required 

Clostridium difficile environmental cleaning 

and infection control training. 

In 2009 and 2010, Environmental 

Management Service staff received 

annual infection prevention training, 

which included environmental cleaning 

for Clostridium difficile. 

Y N 

4. Address general cleanliness in the 

medical intensive care unit, secure and 

properly seal construction access, and 

secure access to soiled utility rooms. 

All items were addressed by the Chief 

of Environmental Management Service 

and continue to be maintained. 

Y N 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

Coordination of Care 

5. Ensure that discharge summaries are 

completed and that they are consistent with 

the discharge instructions provided to 

patients. 

Discharge instructions are provided 

and verified with post-discharge 

telephone calls. 

Y N 

Medication Management 

6. Establish a policy to resolve the conflict 

between the EMR template and the policy 

concerning PRN10 pain assessment and 

documentation. 

The EMR pain template was revised 

immediately following the 2008 CAP 

review. 

Y N 

7. Revise the Bar Code Medication 

Administration policy to reflect the current 

practice. 

Facility policy was revised. Y N 

Emergency/Urgent Care Operations 

8. Ensure all inter-facility transfer 

documentation complies with VHA policy. 

A review by the ED medical director 

demonstrated more than 90 percent 

compliance. 

Y N 

9. Ensure critical equipment monitoring is 

performed and documented, as required by 

facility policy. 

The process for defibrillator checks 

was reviewed with all ED staff and is 

covered annually in mandatory review 

sessions. 

Y N 

10. Ensure nursing staff point-of-care 

competency certification documentation is 

complete. 

ED nursing staff completed 

competency certification during 2009 

and 2010 mandatory reviews. 

Y N 

10 PRN is derived from a Latin phrase “pro re nata” and means “as needed.” 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

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 61.8 68.0 71.7 63.0 61.2 63.3 60.0 66.8 

VISN 62.7 65.5 65.3 63.0 59.5 61.4 60.1 61.8 

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 13 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

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

conditions11 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 13.79 9.83 14.49 20.93 23.52 16.91 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

11 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 14 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date: June 28, 2011
 

From: Director, VISN 4 (10N4)
 

Subject: CAP Review of the VA Pittsburgh Healthcare System,
 

Pittsburgh, PA 

To:	 Director, Baltimore Office of Healthcare Inspections (54BA) 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

I have reviewed the draft report of the VA Pittsburgh Healthcare System. I 

concur with the findings and implemented plans. 

MICHAEL A. MORELAND, FACHE 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: June 24, 2011
 

From: Director, VA Pittsburgh Healthcare System (646/00)
 

Subject: CAP Review of the VA Pittsburgh Health Care System,
 

Pittsburgh, PA 

To: Director, VISN 4 (10N4) 

Listed below are the completed improvement actions for the sixteen 

recommendations received from the Office of the Inspector General for the 

April 2011 Combined Assessment Program review. 

Terry Gerigk Wolf, FACHE 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

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 

PR Committee meeting minutes document actions taken for Level 2 and 3 PRs. 

Concur Target Date for Completion: November 1, 2011 

The Service Chief section of the “Clinical Occurrence Review Form” has been 

expanded to include date, discussion, and actions taken for Peer Review 

Levels 2 and 3. This review form is used by the Peer Review Committee for case 

discussions and content of minutes. All cases designated as a level 2 or 3 will be 

reviewed over a four month time frame to insure that the additional information is 

completed. Committee minutes for the same time frame will be reviewed to determine 

whether or not this information was used in the case discussions. Results will be 

presented at the November meeting of the Executive Leadership Board. 

Recommendation 2. We recommended that processes be strengthened to ensure that 

all PRs that exceed 120 days have extensions requested from and approved by the 

facility Director. 

Concur Target Date for Completion: Completed 

Pending peer reviews are evaluated for timeliness by the Nurse Clinical Reviewer on a 

weekly basis. Fourteen days prior to the 120 day requirement the Chief of Staff will 

send an extension request to the Medical Center Director. For those cases in which an 

extension is not granted, the Chief of Staff will convene a special session of the Peer 

Review Committee in order to close the review process. Medical Center Policy and 

Procedure “Peer Review for Quality Management” has been revised to reflect this 

change. 

Recommendation 3. We recommended that the facility designate and train a PUMA 

and strengthen processes to ensure that cases that do not meet UM criteria are referred 

to the PUMA. 

Concur Target Date for Completion: November 1, 2011 

Sixteen providers have been designated as reviewers and have completed PUMA 

training. This group of providers represents all physician specialties as follows: medical 

specialty – 5, surgical specialty – 4, behavioral health – 5, and critical care – 2. These 

providers are reviewing all cases referred to them. Over a four month period all cases 

not meeting criteria will be tracked to ensure that these were referred to the appropriate 

PUMA. Minutes of the Utilization Review Committee will be reviewed for discussion of 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

PUMA case referrals and associated actions. Progress report will be presented at the 

November meeting of the Executive Leadership Board. 

Recommendation 4. We recommended that processes be strengthened to ensure that 

all required UM data elements are reported. 

Concur Target Date for Completion: November 1, 2011 

In conjunction with the VISN “Utilization Management/Review Policy” the following 

mandatory reporting variables are collected, analyzed, trended, and reported quarterly 

to the Executive Leadership Board: number and percentage of admissions and 

continued stay days meeting criteria in Medicine, Surgery, and Behavioral Health; 

reasons for days not meeting criteria; recommended level of care when criteria not met; 

analysis of physician approval and/or denials of the number of patients not meeting 

criteria during the first level of review; acute bed days of care (BDOC) rate; and, number 

of diversions and reasons for diversion. A four month review of utilization review data 

analysis will be conducted to ensure that all elements as identified have been analyzed 

and appropriately trended. This will include a monthly review of data displays, UM 

Committee minutes, and reports presented to Executive Leadership Board. A progress 

report will be presented at the November meeting of the Executive Leadership Board. 

Recommendation 5. We recommended that processes be strengthened to ensure that 

providers assess and document all required elements prior to performing moderate 

sedation. 

Concur Target Date for Completion: November 1, 2011 

Assessment and documentation requirements prior to administration of conscious 

sedation were reviewed with all appropriate providers. Moderation Sedation Committee 

will perform case reviews from each area using moderate sedation. Data analysis will 

be tracked and trended by provider. Action plans will be required for cases that are 

found to be deficient. A progress report, including four months of data analysis, will be 

presented at the November meeting of the Executive Leadership Board. 

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

data related to resuscitation episodes are analyzed and benchmarked. 

Concur Target Date for Completion: November 1, 2011 

In conjunction with the requirements in the VHA Directive for Oversight and Monitoring 

of Cardiopulmonary Resuscitation Events, the following elements will be added to the 

current aggregate analysis: errors in technique or procedures during resuscitation 

efforts, appropriateness of interventions against the standard of care, clinical issues 

contributing to the resuscitation event, delay in initiating resuscitation, and, 

malfunctioning equipment. Aggregate analysis and identification of trends and/or 

patterns will be done monthly by the CPR Committee. A progress report will be 

provided at the November meeting of the Executive Leadership Board. 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

Recommendation 7. We recommended that processes be strengthened to ensure that 

all required medical record review components are collected, analyzed, and reported. 

Concur Target Date for Completion: November 1, 2011 

Each week a delinquent list for history and physicals and discharge summaries will be 

sent to the respective Service Line Vice President. Daily a list of delinquent operative 

reports will be sent to the Surgical Specialty Service Line. Provider specific information 

is included in each report. A monthly medical record delinquent summary is provided to 

the Clinical Informatics (Medical Record) Committee. Trends by service line will be 

identified. Data will be trended over time. Each quarter a delinquent summary report 

will be provided to the Medical Executive Board. A four month review of this process will 

be conducted. Each month a review of the outlined process will be completed to 

determine compliance. Minutes of Clinical Informatics and Medical Executive Board 

content will be included in the review. A progress report will be provided at the 

November meeting of the Executive Leadership Board. 

Recommendation 8. We recommended that patient complaint data be trended and 

analyzed by the CSC and that CSC meeting minutes be reviewed by a senior-level 

committee. 

Concur Target Date for Completion: November 1, 2011 

The monthly Business Manager meeting serves as the Customer Service Council. 

Effective June 20, 2011 complaint data are sent for review and action as warranted. 

These minutes are reviewed by the Executive Leadership Board. A monthly review of 

data displays for patient complaint data and discussion in the Business Manager 

minutes will be completed for a four month time frame. A progress report will be 

presented at the November meeting of the Executive Leadership Board. 

Recommendation 9. We recommended that the established policy for documentation 

of completed competencies be followed and that responsible staff consistently 

document actions taken when competency deficiencies are identified. 

Concur Target Date for Completion: November 1, 2011 

Competency Assessment Policy is being revised to specifically identify processes for 

validating, tracking, monitoring, and documenting registered nurse competencies. The 

process will include a mechanism to ensure all competency deficiencies are addressed. 

All staff that validates competencies will provide written communication of all 

deficiencies to nurse managers with request for return signatures. This notice will 

include: name, date of competency, notice for action/plan remediation, and, the date by 

which the action must be completed. Deficiency notifications will be sent to the 

Department of Nursing Education where monitoring and follow-up will be tracked. 

Monthly monitors will track nurse manager compliance. Monthly reviews of this tracking 

process will be validated over a four month period. A progress report will be provided at 

the November meeting of the Executive Leadership Board. 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

Recommendation 10. We recommended that processes be strengthened to ensure 

that competency validation documentation is complete and current. 

Concur Target Date for Completion: November 1, 2011 

Competency Assessment Program is being developed to ensure consistent tracking, 

monitoring and documentation of competencies. Competency Assessment Checklists 

are being standardized. Registered Nurse Competency Assessment Program will 

specifically detail how identification; verification/validation; monitoring/tracking; and, 

annual reporting will be accomplished. Nurse Educators will serve as points of contact 

for each division/service. Each will work in collaboration with the Associate Chief 

Nurse, Vice President, and/or the Nurse Manager to monitor and track competency 

compliance and completion. The Nursing Education Department will provide overall 

coordination of the program. A competency database is being created in SharePoint for 

all nursing leaders. Competencies will be able to be tracked and monitored from this 

site. A status report will be provided at the November meeting of the Executive 

Leadership Board. 

Recommendation 11. We recommended that core and unit/position-specific 

competency validation documentation specify the methods used to assess and validate 

competency. 

Concur Target Date for Completion: November 1, 2011 

The unit/position specific competency assessment form is being revised to include the 

following validation methods: demonstration, observation, simulation, written test, or 

verbalization. A validation process is being established in order to ensure all 

documentation has been completed. The validation process will require the signatures 

of the individual assessing the competency, nurse educator, and nurse manager. Over 

a four month time frame, registered nurse competencies completed each month will be 

reviewed for the documentation of the method of validation. A progress report will be 

given at the November meeting of the Executive Leadership Board. 

Recommendation 12. We recommended that managers specify the qualifications 

required for individuals who perform RN competency assessment and validation. 

Concur Target Date for Completion: November 1, 2011 

Nurse Managers will identify the qualifications required for all staff who participates in 

the competency validation process for registered nurses. Qualifications will ensure that 

staffs that assess and validate competencies have the corresponding education, 

knowledge, skill, and experience commensurate with the skill being validated. This will 

be reflected in the new Competency Assessment Policy. A progress report will be 

provided at the November meeting of the Executive Leadership Board. 

Recommendation 13. We recommended that N95 respirator fit testing be completed 

annually and that compliance be monitored. 

Concur Target Date for Completion: November 1, 2011 

VA OIG Office of Healthcare Inspections 20 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

A Respiratory Protection Program has been implemented that is in accordance with all 

OSHA requirements. Fit testing and training sessions are conducted throughout the 

year by an independent contractor. During interim periods fit testing is done by 

Industrial Hygiene Staff. Each month, fit test records are compared to Service Line staff 

rosters to ensure that employees who require respiratory protection have been fit 

tested. Powered air purifying respirators (PARS) are used to supplement 

N-95 respirators for those with facial hair or who fail fit testing. PARS are located on the 

inpatient units and the emergency department. PARS are also used by those 

employees who for whatever reason are unable to wear a standard N-95 respirator. All 

employees who currently require respiratory protection have been fit tested. A monthly 

review will be completed for a four month time frame of fit-testing for randomly selected 

high risk areas. A progress report will be presented at the November meeting of the 

Executive Leadership Board. 

Recommendation 14. We recommended that the facility ensure privacy for women 

patients in the SDS unit. 

Concur Target Date for Completion: Completed 

Room 9W107, with private bathroom, was designated as the secure and private female 

changing room for the Same Day Surgery Unit. All female Veterans are required to 

wear hospital gown, robe, and slippers. By the end of FY11, the new SDS unit will 

open. The new design includes individual patient bays for privacy. 

Recommendation 15. We recommended that pharmacy staff who compound 

chemotherapy medications remove outer gloves before exiting the BSC and don new 

outer gloves before re-entering the BSC. 

Concur Target Date for Completion: Completed 

All pharmacists and pharmacy technicians competent to compound chemotherapy and 

other hazardous medications were provided a copy of the ASHP Guidelines for 

Handling Hazardous Drugs. The Pharmacy Program Leader discussed with staff the 

specific guidelines pertaining to the appropriate use of gloves and necessity to remove 

outer gloves prior to removing hands from the biological safety cabinet in order to 

prevent chemotherapy and other hazardous medications from contaminating 

surrounding areas. Gloves must then be reapplied and sterilized prior to returning 

hands to the biological safety cabinet. A quick reference gloving guide was developed 

and posted for staff reference. 

Recommendation 16. 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 EMR. 

Concur Target Date for Completion: Completed 

The following has been added to assessment templates in the electronic medical 

record: “Patient verbalized they received written notification regarding their right to 

accept or refuse medical treatment, to designate a Health Care Agent, and to document 

VA OIG Office of Healthcare Inspections 21 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

their treatment preferences in an advanced directive.” This addition also includes an 

entry to indicate a patient’s level of consciousness or cognitive status. In those cases in 

which there is an altered level of consciousness, the information is reviewed with the 

next of kin and/or guardian. The template provides for the entry of this information. The 

assessment templates include: psychosocial assessment, history and physical, medical 

student history and physical, preoperative history and physical consultation, history and 

physical short version, and nursing admission assessment. This is a forced field entry 

in each of the templates. 

VA OIG Office of Healthcare Inspections 22 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

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 Melanie Cool, LD, Project Leader 

Sonia Whig, LD, Team Leader 

Don Braman, RN 

Jennifer Christensen, DPM 

Frank Miller, PhD 

Judith Thomas, RN 

Timothy Barry, Special Agent, Office of Investigations 

VA OIG Office of Healthcare Inspections 23 
CAP Review of the VA Pittsburgh Healthcare System, Pittsburgh, PA 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VISN 4 (10N4) 

Director, VA Pittsburgh Healthcare System (646/00) 

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: Sherrod Brown; Robert P. Casey, Jr.; Joe Manchin, III; Rob Portman; 

John D. Rockefeller, IV; Patrick J. Toomey 

U.S. House of Representatives: Mark Critz, Mike Doyle, Bob Gibbs, Bill Johnson, 

David McKinley, Tim Murphy 

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

VA OIG Office of Healthcare Inspections 24