Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Contract Community Based 

Outpatient Clinic Issues 

New Mexico VA Health Care System 

Albuquerque, New Mexico 

Report No. 11-00588-189 June 8, 2011 VA Office of Inspector General 

Washington, DC 20420 
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) 
Contract CBOC Issues, New Mexico VA Health Care System, Albuquerque, New Mexico 

Executive Summary 

The VA Office of Inspector General Office of Healthcare Inspections conducted a review 

to determine the validity of allegations regarding patient care at contract community 

based outpatient clinics (CBOCs) affiliated with the New Mexico Veterans Affairs 

Healthcare System. The confidential complainant alleged that: 

	 Contract issues negatively impacted patient care. 

	 A CBOC physician underwent three level-III peer reviews (PRs) following the 

death of a patient. 

	 From April to September 2010, four patients with positive colorectal cancer 

(CRC) screening tests were not referred to a gastrointestinal specialist to 

determine the cause for bleeding. 

	 There were numerous complaints from veterans unable to get access to care when 

needed. 

We substantiated the allegation that contract issues negatively impacted patient care. 

Although not required by the contract, the facility contracting office directed that 

communication be routed through their staff, which caused delays in handling patient 

care matters. 

We did not substantiate that there were three level-III PRs assigned to a CBOC physician. 

However, we did find issues related to PR timeliness and confidentiality when the results 

were communicated to facility contracting staff. 

We did not substantiate the allegation regarding positive CRC screenings for 

four patients. We found the facility was not timely in referring patients for colonoscopies 

following positive CRC screening tests; however, they had an acceptable action plan. 

We substantiated that there were issues with access to care at the CBOC. The extent of 

the problem could not be determined because the CBOC did not follow Veterans Health 

Administration requirements for scheduling patients and monitoring access, and the 

facility patient advocates did not document and track patient complaints. 

We recommended that the Network Director ensure free and direct clinical information 

between the facility and El Centro Family Health staff. We also recommended that 

facility managers assure timeliness and confidentiality of peer reviews; and that CBOCs 

follow Veterans Health Administration requirements for monitoring access to care and 

patient satisfaction. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS 

Office of Inspector General 

Washington, DC 20420 

TO: Director, VA Southwest Health Care Network (10N18) 

SUBJECT: Healthcare Inspection – Contract Community Based Outpatient Clinic 

Issues, New Mexico VA Health Care System, Albuquerque, New 

Mexico 

Purpose 

The VA Office of Inspector General Office of Healthcare Inspections conducted an 

inspection to determine the validity of allegations made by a confidential complainant 

regarding patient care at two contract community based outpatient clinics (CBOCs) 

affiliated with the New Mexico Veterans Affairs Healthcare System (facility). 

Background 

The facility is located in Albuquerque, New Mexico and is a member of Veterans 

Integrated Service Network (VISN) 18. The facility operates 310 beds and oversees 

10 CBOCs that provide services in New Mexico and southwest Colorado. 

This inspection relates to contract care provided by El Centro Family Health (ECFH) 

staff at the Espanola and Las Vegas, NM CBOCs. ECFH provided contracted primary 

and mental health outpatient care to about 1800 enrolled veterans under the current 

contract since January 1, 2005, and for 15 years under previous contracts. The most 

recent contract included 4 option years, which extended the service through 

December 31, 2009. Through a series of contract extensions and an interim contract, 

ECFH is expected to continue to provide contracted care through March 2011. 

In November 2010, a confidential complainant alleged that: 

	 Contract issues negatively impacted patient care. 

	 A CBOC physician underwent three level-III peer reviews (PRs)1 following the 

death of a patient. 

1 A PR is a process that requires evaluation of a physician’s competence and conduct by another physician or 

professional group. A level-III PR means that the reviewer(s) would have definitely managed the subject case 

differently. 

VA Office of Inspector General 1 
Contract CBOC Issues, New Mexico VA Health Care System, Albuquerque, New Mexico 

	 From April to September 2010, four patients with positive colorectal cancer 

(CRC) screening tests were not referred to a gastrointestinal (GI) specialist to 

determine the cause of bleeding. 

	 There have been numerous complaints from veterans not being able to get access 

to care when needed. 

Scope and Methodology 

We conducted a site visit January 10–13, 2011, and interviewed key facility staff, 

including contracting staff, as well as ECFH contracted staff and management. In 

preparation for this site visit, we reviewed the contract (beginning January 1, 2005) and 

the contracting office’s correspondence files with ECFH. We also reviewed selected 

patient medical records, pertinent medical center documents, performance measure data, 

and applicable facility and Veterans Health Administration (VHA) policies. 

This review was performed in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of the Inspectors General on Integrity and 

Efficiency. 

Inspection Results 

Issue 1: Contract Issues Impacted Patient Care 

We substantiated the allegation that contract issues negatively impacted patient care. 

The facility contracting office, under the guidance of the network contracting office, is 

responsible for administering the contract and for addressing performance issues. 

Although the contract does not contain any provisions that prohibit clinical and quality 

management communication between providers, the facility contracting office directed 

that all communication between the system and ECFH go through the contracting office. 

Our interviews with both facility and contractor clinical staff corroborated that they were 

not allowed to speak directly unless the Contracting Officer’s Technical Representative 

or another contracting office representative was present. 

We found that the requirement for all communication to go through the contracting office 

caused undue delays and negatively impacted patient care. Providers expressed 

frustration that coordination of patient health care was impacted by the communication 

limits placed on them. The exchange of clinical information between providers is 

essential for the optimum coordination of patient care. 

Recommendation 1: We recommended that the Network Director ensure coordination 

of patient care through sharing pertinent clinical information directly between the facility 

and clinical staff at all CCBOCs. 

VA Office of Inspector General 2 
Contract CBOC Issues, New Mexico VA Health Care System, Albuquerque, New Mexico 

Issue 2: Physician with Multiple Level-III Peer Reviews 

We did not substantiate that a CBOC physician underwent three level-III PRs following 

the death of a patient. The facility took appropriate actions following the notification of a 

patient death at a non-VA medical facility; however, we found opportunities for 

improvement in the PR process. 

VHA defines PR as: 

An organized process carried out by an individual health care professional 

or select committee of professionals, to evaluate the performance of other 

professionals. In the health care setting, PR is applied to a broad array of 

activities of varying characteristics; this includes, but is not limited to: 

reviews done for Quality Management; Management Reviews like 

Administrative Investigation Boards (AIB); Clinical Practice reviews; 

Ongoing Professional Practice Evaluations (OPPE); Tort Claims; and 

National Practitioner Data Bank (NPDB) reporting.2 

VHA requires that the need for PR be determined for a variety of reasons including when 

a patient dies at a non-VA facility.3 Upon notification that a CBOC-managed patient 

died at non-VA facility, facility clinicians screened the case and determined that a PR 

was required. Subsequent to the PR, the facility performed additional performance 

monitoring on the subject physician using Focused Professional Practice Evaluation4 

(FPPE) with nomenclature similar to that used in PRs, which gave an impression of 

multiple reviews. 

VHA requires that all PRs be completed within 120 days and that “PRs conducted as part 

of a quality management program may not be disclosed outside of the quality 

management process.” To maintain the integrity of the PR process for the continuous 

improvement of patient care, confidentiality must be maintained when individual 

providers, patients, or other employees are identified. Therefore, PRs should be 

communicated from the PR committee to the provider’s service chief and then to the 

provider. 

The facility took 7 months to complete the PR. The facility completed the initial peer 

review within the 45-day VHA requirement. However, the facility did not have a defined 

process for communicating PR results to contract providers. The facility took an 

additional 3 months to notify the contract provider of the PR results. The facility 

disclosed the PR results outside of the quality management process to contracting staff 

2 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010. 3 VHA Directive 2010-025. 4 According to VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008, FPPE may be used 

when there is a question about a physician’s ability to provide safe, high quality patient care. 

VA Office of Inspector General 3 
Contract CBOC Issues, New Mexico VA Health Care System, Albuquerque, New Mexico 

before communicating the results to the subject physician, which violated the 

confidentiality provision of PR. 

Recommendation 2: We recommended that facility managers ensure that there is a 

well-defined process for communicating level II and III PRs to contract providers in a 

manner that supports the confidentiality and timeliness of the PR quality management 

process. 

Issue 3: Positive Colorectal Cancer Test Patients 

We did not substantiate the allegation that patients with positive CRC screening tests 

were not referred to a gastrointestinal specialist for follow-up evaluations. 

VHA requires that a screening colonoscopy be completed within 60 days of a positive 

CRC test.5 A patient with a positive CRC test must undergo a screening colonoscopy to 

confirm any suspicion of cancer. 

We reviewed the medical records of the four subject patients. We found three patients 

with positive CRC tests had consultations to GI service. The fourth patient did not have a 

positive CRC test. We found that clinicians appropriately screened for and managed 

positive CRC test results by consulting with specialty providers. However, in the 

three subject cases the facility did not meet the 60-day requirement for screening 

colonoscopy following a positive CRC screening test. The facility showed evidence of 

adequate action plans implemented to meet the 60-day timeframe; therefore, we made no 

recommendations. 

Issue 4: Patient Complaints about Access to Care 

We substantiated the allegation that patients had complaints about access to care. 

According to the contract, ECFH is expected to follow VHA performance criteria for 

access and patient satisfaction. Therefore, ECFH staff is expected to monitor the percent 

of unique primary care patients on the access list waiting more than 14 days from their 

desired date for an appointment6 and report patient complaints according to 

requirements.7 

VHA requires that access to care be measured and monitored.8 ECFH serves veteran and 

non-veteran patients, and uses a scheduling-software package that differs from that of the 

facility. The ECFH software does not allow for measurement of access to care as 

required by VHA. In contrast, the facility scheduling-software9 does allow for 

5 VHA Directive 2007-004, Colorectal Cancer Screening, January12, 2007. 6 VHA Office of Quality and Performance, FY 2011 Technical Manual, Oct 1, 2010. 7 VHA Directive 2006-041, Veterans Health Care Service Standards, June 27, 2006. 8 VHA Office of Quality and Performance, FY 2011 Technical Manual, October 1, 2010. 9 The facility uses VA software and client-server technology, Veterans Health Information Systems and Technology 

Architecture (VistA). 

VA Office of Inspector General 4 
Contract CBOC Issues, New Mexico VA Health Care System, Albuquerque, New Mexico 

measurement of access to care. Patient care may be negatively impacted by inadequate 

access to care. Because the ECFH staff did not measure access to care as required by 

VHA, it was not possible to obtain a clear picture of CBOC scheduling issues. 

VHA also requires that facility patient advocates receive and electronically record patient 

complaints, compliments, and other patient issues in the Patient Advocate Tracking 

System (PATS).10 Management is responsible for evaluating PATS data to identify 

opportunities for facility improvements and integrate the information with the facility, 

VISN, and national quality management reports. We substantiated that there were 

numerous complaints about access to care at the CBOC, and interviews with key facility 

staff confirmed this finding. We also found that PATS was not being used in accordance 

with VHA requirements and documentation of complaints and reports on access wait 

times was lacking. Facility staff reported complaints, but there were only 

two documented complaints in the PATS during fiscal year 2010. We found that facility 

staff did not follow VHA guidelines on the use of the PATS and, therefore, were not able 

to determine the number or the nature of complaints. Moreover, managers were unaware 

of patient concerns, and opportunities for improvement were missed. 

Recommendation 3: We recommended that the facility ensure that all CBOCs adopt the 

facility scheduling software package and monitor access to care, as required by VHA. 

Recommendation 4: We recommended that facility staff follow VHA’s guidelines on 

the PATS. 

Conclusions 

Although the contract did not contain language prohibiting direct contact between staff, 

the facility implemented this requirement, which caused preventable delays in 

communication of clinical matters, including delays in handling PRs on a CBOC 

physician. We found the subject physician’s cases were reviewed according to protocol; 

however, we did find issues related to PR timeliness and confidentiality. 

We did not substantiate the allegation about CRC follow-up. However, we found there 

was delay in the handling of follow-up evaluations. The facility is taking significant 

steps to support their increased demand for follow-up colonoscopies. 

The CBOC did not follow VHA requirements for scheduling patients and monitoring 

access, and patient advocates did not document and track patient complaints as per VHA 

policy. We found there were issues with access and patient satisfaction, but it was not 

possible to determine the extent of the problem due to the lack of documentation. We 

concluded that in order to provide coordinated patient care the system must ensure that 

CBOCs comply with implementation of VHA scheduling software and monitor access to 

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

VA Office of Inspector General 5 
Contract CBOC Issues, New Mexico VA Health Care System, Albuquerque, New Mexico 

care. We also concluded that to identify areas for facility improvement CBOCs must 

follow VHA systems for tracking and reporting patient satisfaction. 

Comments 

The VISN and System Directors concurred with the inspection results (see Appendixes A 

and B, pages 7–10, for the full text of the Directors’ comments). We will follow-up on 

the planned actions until they are complete. 

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

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General 6 
Contract CBOC Issues, New Mexico VA Health Care System, Albuquerque, New Mexico 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 May 9, 2011 

From:	 Director, VA Southwest Health Care Network (10N18) 

Subject:	 Healthcare Inspection – Contract Community Based Outpatient 

Clinic Issues, New Mexico VA Healthcare System, Albuquerque, 

NM 

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

Thru:	 Director, Management Review Service (10B5) 

1. I concur with the facility response to the Healthcare 

Inspection report. Please see Facility Director Comments for 

specific actions. 

2. For questions, please contact Sally Compton, 

Executive Assistant to the Network Director, VISN 18, at 

602.222.2699. 

(original signed by:) 

Susan P. Bowers 

Director, VA Southwest Health Care Network (10N18) 

VA Office of Inspector General 7 
ues,

enter Director Comments

co VA Health Care System (501/00)

n

ic

que

hwest Health

your request

our facility.

y que

mela Crowell, Chief, Performance Improvement,

(extension 2092).

ico VA Health Care System (501/00)

Contract CBOC Is rque, New Mexico

Medical

Department of

Veterans Affai m

Director, New

Healthcare In

Outpatient re

System, A

VA

In response find

a response from

If you have n,

please contact ment,

ew

Albuqu

Memorandu

, please

stions or require additional inform

please contact Pamela Crowell, Chief, Performance Impr

Contract CBOC Issues, New Mexico VA Health Care System, Albuquerque, New Mexico 

Appendix B 

Medical Center Director Comments 

Department of 

Veterans Affairs Memorandu m 

Date:	 May 9, 2011 

From:	 Director, New Mexico VA Health Care System (501/00) 

Subject:	 Healthcare Inspectio spection – Contract Community Based

Outpatient Clinic Issues, New Mexico VA Healthcare Healthca

System, Albuquer lbuquerque, New Mexico 

To:	 Director, VA Southwest Health Care Network (10N18) 

1. In response to your request, dated April 16, 2011, please find 

a response from our facility. 

2. If you have any questions or require additional information, 

please contact Pamela Crowell, Chief, Performance Improvement, 

at 505-265-1711 (extension 2092). 

George Marnell 

Director , New Mexico VA Health Care System (501/00) 

VA Office of Inspector General 8 
Contract CBOC Issues, New Mexico VA Health Care System, Albuquerque, New Mexico 

Director’s 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’s report: 

OIG Recommendations 

Recommendation 1. We recommended that the Network Director ensure 

coordination of patient care through sharing pertinent clinical information 

directly between the facility and clinical staff at all CCBOCs. 

Concur Target Completion Date: August 1, 2011 (10F) 

Facility’s Response: 

To improve the flow of communications between the facility and clinical 

staff at all community-based outpatient clinics (CBOCs) and to improve 

patient care, a specific communication protocol to address this issue will be 

added to existing Contracting Office Technical Representative (COTR) 

training. In addition, the Veterans Health Administration (VHA) 

Procurement and Logistics Office, Medical Sharing Office, is coordinating 

with VHA Patient Care Services to revise the CBOC template to address 

communication issues. These changes will be implemented at the Espanola 

CBOC. 

Status: Open 

Recommendation 2. We recommended that facility managers ensure that 

there is a well-defined process for communicating level II and III PRs to 

contract providers in a manner that supports the confidentiality and 

timeliness of the PR quality management process. 

Concur Target Completion Date: May 9, 2011 

Facility’s Response: 

The NMVAHCS has changed the Peer Review Policy to include the 

following language under procedures: “In the event the Peer Review 

Committee determines a level II or level III for a provider in a contract 

CBOC, the Chief of Staff will communicate the Peer Review Committee 

VA Office of Inspector General 9 
Contract CBOC Issues, New Mexico VA Health Care System, Albuquerque, New Mexico 

Level II or Level III determination directly to the Medical Director of the 

Contract Community Based Outpatient Clinic.” 

Status: Closed 

Recommendation 3. We recommended that the facility ensure that all 

CCBOCs adopt the facility scheduling software package and monitor 

access to care, as required by VHA. 

Concur Target Completion Date: April 1, 2011 

Facility’s Response: 

The New Mexico VA Health Care System has incorporated this 

requirement into all Contract CBOC Scopes of Work, including the 

Northern New Mexico Contract CBOC. The new contractor began work on 

April 1, 2011, and is using the facility scheduling software package. 

Additionally, access is monitored and reported every 2 weeks to senior 

leadership. This report is also monitored monthly at the Systems Redesign 

Steering Committee. 

Status: Closed 

Recommendation 4. We recommended that facility staff follow VHA’s 

guidelines on PATS. 

Concur Target Completion Date: April 15, 2011 

Facility’s Response: 

The NMVAHCS has a standing policy on Patient Complaints and entry of 

complaints into the PATS. Since January 2011, communication efforts 

have increased to remind staff to enter complaints into the PATS system, 

including complaints from the Espanola CBOC. NMVAHCS Rural Health 

staff completed PATS training in January 2011 and is now entering all 

compliments, complaints and other patient care issues in the PATS. 

Status: Closed 

VA Office of Inspector General 10 
Contract CBOC Issues, New Mexico VA Health Care System, Albuquerque, New Mexico 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact	 For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720 

Acknowledgments	 Murray Leigh, CPA, Project Manager 

Sonia Whig, LD, Co-Team Leader 

Zhana Johnson, CPA, Co-Team Leader 

Melanie Cool, LD 

Nathan Fong, CPA 

Donna Giroux, RN 

Cathleen King, RN 

Nelson Miranda, LCSW 

VA Office of Inspector General 11 
Contract CBOC Issues, New Mexico VA Health Care System, Albuquerque, New Mexico 

Appendix D 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Southwest Health Care Network (10N18) 

Director, New Mexico VA Health Care System (501/00) 

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 

US Senate: Jeff Bingaman, Tom Udall 

US House of Representatives: Martin Heinrich, Steve Pearce, Ben Luján 

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

VA Office of Inspector General 12