Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-00029-193 

Combined Assessment Program
 

Review of the
 

Northampton VA Medical Center
 

Leeds, Massachusetts
 

June 13, 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 Northampton VA Medical Center, Leeds, MA 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CARF Commission on Accreditation of Rehabilitation 

Facilities 

CLC community living center 

COC coordination of care 

CREW Civility, Respect, and Engagement in the Workplace 

EOC environment of care 

facility Northampton VA Medical Center 

FPPE Focused Professional Practice Evaluation 

FY fiscal year 

HUD-VASH Housing and Urban Development –Veterans Affairs 

Supportive Housing 

IC infection control 

MDRO multidrug-resistant organisms 

MSEC Medical Services Executive Committee 

OIG Office of Inspector General 

OPPE Ongoing Professional Practice Evaluation 

PI performance improvement 

PRC Peer Review Committee 

PSB Professional Standards Board 

PTSD post-traumatic stress disorder 

QM quality management 

RN registered nurse 

SARRTP Substance Abuse Residential Rehabilitation 

Treatment Program 

SOARS Systematic Ongoing Assessment and Review 

Strategy 

UCC urgent care clinic 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

Table of Contents
 

Page
 

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

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

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

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

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

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

Review Activities With Recommendations .............................................................. 3
 

QM..................................................................................................................... 3
 

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

COC .................................................................................................................. 5
 

Management of Test Results............................................................................. 5
 

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

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

Management of MDRO...................................................................................... 6
 

Comments................................................................................................................... 6
 

Appendixes 

A. Facility Profile .................................................................................................... 7
 

B. Follow-Up on Previous Recommendations........................................................ 8
 

C. VHA Satisfaction Surveys ................................................................................. 11
 

D. VISN Director Comments .................................................................................. 12
 

E. Facility Director Comments ............................................................................... 13
 

F. OIG Contact and Staff Acknowledgments ......................................................... 17
 

G. Report Distribution ............................................................................................ 18
 

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

Review of the Northampton VA Medical Center, Leeds, MA 

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 

March 7, 2011. 

Review Results: The review covered 

six activities. We made no 

recommendations in the following 

activities: 

	 Environment of Care 

	 Management of Multidrug-Resistant 

Organisms 

The facility’s reported accomplishments 

were an innovative program for staff 

orientation and training, the patient 

safety program, and a multi-faceted 

program for homeless veterans. 

Recommendations: We made 

recommendations in the following four 

activities: 

Quality Management: Include the active 

participation of all required members of 

senior leadership in the Quality Council. 

Establish a process to prioritize 

performance improvement projects. 

Ensure that quality management 

committees consistently implement 

action items, track open action items to 

completion, monitor the effectiveness of 

actions, and modify ineffective actions. 

Ensure that the Peer Review Committee 

is notified of all completed corrective 

actions. 

Physician Credentialing and Privileging: 

Ensure that a Focused Professional 

Practice Evaluation is completed for all 

physicians who were either newly hired 

or added new privileges and that 

Credentialing and Privileging Committee 

meeting minutes reflect sufficient 

discussion of the performance data 

used to make privileging and 

reprivileging decisions. 

Coordination of Care: Update the local 

policy for management of advance care 

planning/advance directives to be 

consistent with current Veterans Health 

Administration policy, and monitor 

compliance with the updated policy. 

Management of Test Results: Ensure 

normal test results are communicated to 

patients within the specified timeframe, 

and periodically monitor the 

communication process for 

effectiveness. 

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 Northampton VA Medical Center, Leeds, MA 

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: 

	 COC 

	 EOC 

	 Management of MDRO 

	 Management of Test Results 

	 Physician C&P 

	 QM 

The review covered facility operations for FY 2010 and 

FY 2011 through February 28, 2011, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. We also followed up on recommendations from our 

prior CAP review of the facility (Combined Assessment 

Program Review of the Northampton VA Medical Center, 

Leeds, Massachusetts, Report No. 07-03175-09, 

October 16, 2008). The facility had corrected 16 of the 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

17 findings from our previous review. (See Appendix B for 

further details.) 

During this review, we also presented crime awareness 

briefings to 108 employees. These briefings covered 

procedures for reporting suspected criminal activity to the 

OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. 

Reported Accomplishments
 Staff Education	 To achieve its goal to create and foster a culture of 

continuous engagement and improvement, the facility 

created and implemented a novel, hands-on new employee 

orientation exercise. This was accomplished by 

incorporating teamwork and improvement concepts using 

CREW training and systems redesign. The exercise was 

incorporated into a 4-hour program intended for all facility 

employees. This training is the prerequisite for more 

advanced training offered by VISN 1 in conjunction with 

Purdue University. 

Patient Safety	 The facility’s patient safety program was a FY 2010 recipient 

Program of a Bronze Cornerstone Award for root cause analysis. 

Cornerstone Awards, presented by the VA National Center 

for Patient Safety, recognize leaders in VA patient safety at 

the facility level. The program, also cited as excellent by 

CARF and SOARS review teams, has been recognized as a 

leader in achieving the best practices in acute mental health 

psychiatric inpatient EOC. 

Homeless Veterans	 The facility coordinates one of the larger programs 

Program nationwide serving homeless veterans. It provides 

emergency contract beds and outreach services through a 

multi-faceted effort that includes the VA Grant and Per Diem 

Program, the HUD-VASH Program, the Veteran Justice 

Outreach Initiative, and homeless dental programs. The 

program also serves homeless women and veterans with 

chronic mental illnesses. Overall, 225 beds are provided in 

partnership with Soldier On®, a private, non-profit agency 

that maintains shelters on facility grounds and in 

Pittsfield, MA. To date, the program has placed 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

137 homeless veterans with chronic mental illness into 

permanent housing. 

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. 

QM Senior Leadership Committee. VHA requires each 

facility to identify an active senior-level committee that 

includes the Director, Chief of Staff, Nursing Executive, 

Quality Manager, and Patient Safety Manager.1 We found 

that the facility’s senior leadership committee, the Quality 

Council, did not meet the intent of the VHA directive for 

senior leadership and medical staff participation in the QM 

process. Local policy for the Quality Council does not 

include the Patient Safety Manager, and it identifies the 

Director, Chief of Staff, and Nursing Executive as non-voting 

members. Council meeting minutes did not demonstrate 

active participation by senior management or medical staff in 

the PI process. In addition, local policy requires the council 

to prioritize PI projects by reviewing proposals; however, 

there was no evidence a prioritization process had been 

established. 

QM Data Management. VHA requires each facility to provide 

oversight to ensure that QM components are implemented, 

integrated, and documented.2 We found that the Quality 

Council, the PRC, the MSEC, and the Medical Record 

Review Committee did not consistently implement action 

items, track implemented action items to completion, monitor 

the effectiveness of implemented actions, and modify actions 

found to be ineffective. This was a repeat finding from the 

previous CAP review. 

1 VHA Directive 2009-043, Quality Management System, September 11, 2009. 2 VHA Directive 2009-043. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

Peer Review. VHA requires that the PRC receive notification 

upon completion of corrective actions.3 We found that PRC 

minutes did not indicate that completed corrective actions for 

Level 3 reviews were discussed during committee meetings. 

Recommendations	 1. We recommended that the Quality Council include the 

active participation of all required members of senior 

leadership. 

2. We recommended that the Quality Council establish a 

process to prioritize PI projects. 

3. We recommended that processes be strengthened to 

ensure that QM committees consistently implement action 

items, track open action items to completion, monitor the 

effectiveness of implemented actions, and modify ineffective 

actions. 

4. We recommended that that the PRC be notified when 

corrective actions are completed. 

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 areas that needed improvement. 

FPPE. VHA requires that an FPPE be completed for all 

physicians who have been newly hired or have added new 

privileges.4 We reviewed the profiles of three newly hired 

physicians and one physician requesting a new privilege. 

Two of the four physicians did not have FPPEs. 

C&P Committee. VHA requires that the C&P Committee 

consider and discuss professional performance when 

granting original privileges and prior to reprivileging and that 

the minutes reflect those discussions.5 C&P Committee 

meeting minutes did not reflect adequate discussion for any 

of the 12 physicians. 

3 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010. 4 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 5 VHA Handbook 1100.19. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

Recommendations 

COC 

Recommendation 

Management of 

Test Results 

5. We recommended that FPPEs be completed for all 

physicians who have been newly hired or have added new 

privileges. 

6. We recommended that C&P Committee meeting 

minutes reflect sufficient discussion of the performance data 

used to make privileging and reprivileging decisions. 

The purpose of this review was to evaluate whether the 

facility managed advance care planning, advance directives, 

and discharges in accordance with applicable requirements. 

We reviewed patients’ medical records for evidence of 

advance care planning, advance directives, and discharge 

instructions. We identified the following areas that needed 

improvement. 

Advance Care Planning/Advance Directives Policy. VHA 

requires that health care staff follow specific procedures for 

advance care planning/advance care directives.6 Local 

policy had not been updated to be consistent with current 

VHA policy. For example, we found that documentation was 

lacking regarding notification to patients of their right to 

accept or refuse medical treatment, to designate a Health 

Care Agent, and to document their treatment preferences in 

an advance directive. Additionally, required note titles were 

not used to identify advance care planning discussions with 

patients or to indicate when an advance directive had been 

executed. 

7. We recommended that local policy for management of 

advance care planning/advance directives be updated to be 

consistent with current VHA policy and that compliance with 

the updated policy be monitored. 

The purpose of this review was to follow up on a previous 

review that identified improvement opportunities related to 

documentation of notification of abnormal test results and 

follow-up actions taken.7 

We reviewed the facility’s policies and procedures, and we 

reviewed medical records. We identified the following area 

that needed improvement. 

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

7 Healthcare Inspection Summary Review – Evaluation of Veterans Health Administration Procedures for 

Communicating Abnormal Test Results, Report No. 01-01965-24, November 25, 2002. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

Communication of Normal Results. VHA requires facilities to 

communicate normal results to patients no later than 

14 calendar days from the date that the results were 

available to the ordering provider.8 We reviewed the medical 

records of 20 patients who had normal results and found that 

7 of the 20 records lacked documentation that clinicians 

communicated the results to patients. 

Recommendation	 8. We recommended that normal test results be 

consistently communicated to patients within the specified 

timeframe and that the communication process be 

periodically monitored for effectiveness. 

Review Activities Without Recommendations
 

EOC	 The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

We inspected the acute mental health, chronic mental health, 

PTSD, CLC, and SARRTP units; radiology; the UCC; and the 

dental and primary care clinics. The facility maintained a 

generally clean and safe environment. We made no 

recommendations. 

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

MDRO facility had developed a safe and effective program to reduce 

the incidence of MDRO in its patient population in 

accordance with applicable requirements. 

We reviewed the facility’s IC risk assessment, employee 

training records, and medical records. We inspected the 

CLC and interviewed employees. We determined that the 

facility had an effective program in place. 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 12–16 for full text of the Directors’ comments.) We will follow up on the 

planned actions until they are completed. 

8 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

Appendix A 

Facility Profile9 

Type of Organization Medical center 

Complexity Level 3 

VISN 1 

Community Based Outpatient Clinics Springfield, MA 

Greenfield, MA 

Pittsfield, MA 

Veteran Population in Catchment Area 59,756 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

81 

 CLC/Nursing Home Care Unit 48 

 Domiciliary 16 

Medical School Affiliation(s) None 

 Number of Residents 0 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

December 2010 

except where 

noted) 

$103.3 

Prior FY (2010) 

$130 

 Medical Care Expenditures $29.6 $130 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

605 

9,651 (as of 

November 30, 2010) 

582 

607.5 

15,152 

2,893 

o CLC/Nursing Home Care Unit 4,058 15,987 

Hospital Discharges 251 1,072 

Total Average Daily Census (including all bed 

types) 

128.2 128 

Cumulative Occupancy Rate (in percent) 88.4 88.3 

Outpatient Visits 33,595 191,238 

9 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

EOC 

1. Ensure personnel monitor hand hygiene 

compliance and initiate corrective actions 

when monitors fall below established 

thresholds. 

Compliance monitored by direct 

observation; data tracked by IC staff 

and reported to IC Committee. 

Y N 

2. Ensure that the ceiling and roof over the 

food preparation area in the canteen kitchen 

is permanently repaired. 

Repairs completed to kitchen ceiling 

and exterior roof. 

Y N 

3. Ensure that the Wanderguard® System10 

is tested and maintained and that 

maintenance is documented. 

Logs of daily testing by nursing staff 

maintained in units. Electronic logs of 

maintenance by engineering and 

repairs by vendor also maintained. 

Y N 

4. Ensure that the medication and patient 

nutrition refrigerator logs reflect acceptable 

temperature ranges and include contact 

information for maintenance. 

Hard copy logs maintained on each 

unit are compliant. Installation to begin 

on centralized electronic system to 

monitor temperatures. 

Y N 

5. Ensure that suicide prevention materials 

are posted in patient care areas throughout 

the facility. 

Posters, brochures, and wallet cards 

are available throughout the facility. 

Y N 

6. Ensure that emergency carts are 

inspected in accordance with facility policy. 

Inspections completed, documented, 

and reported to the Quality Council. 

Y N 

10 Electronic system to help manage the wandering risks of patients with Alzheimer’s disease and other forms of dementia. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM Program 

7. Ensure that clinical managers implement 

a peer review policy and that the PRC fulfills 

all required functions. 

PRC members have received training, 

meet quarterly, and are reporting peer 

review data to the MSEC. 

Y N 

8. Implement a continuous performance 

monitoring plan, and collect and analyze 

provider PI data as part of the reprivileging 

process for all providers. 

Service line managers have developed 

specific performance criteria for OPPE, 

and the PSB incorporated performance 

analysis based upon those specific 

criteria into the reprivileging process. 

Y N 

9. Ensure that managers monitor the 

effectiveness of all corrective actions and 

modify actions when they prove to be 

ineffective. 

QM managers do not consistently 

implement and document action items, 

track implemented items to completion, 

test the effectiveness of actions, or 

modify an action if ineffective. 

N Y (see pages 3–4) 

10. Ensure radiology managers establish 

benchmarks to monitor the timeliness of 

radiology studies performed by fee basis 

agencies, and analyze data to identify trends. 

Radiology managers have developed a 

process to analyze timeliness data and 

are reporting analysis monthly to the 

MSEC. 

Y N 

Emergency Department/UCC 

11. Ensure that the UCC provides written 

discharge instructions to patients. 

Template for UCC discharge 

instructions developed and 

implemented. 

Y N 

12. Ensure that the UCC complies with VHA 

policy governing inter-facility transfers. 

Process to ensure completion of 

inter-facility transfer documentation 

implemented. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

13. Ensure that all RNs who work in the 

UCC during administrative and 

non-administrative hours achieve the 

required clinical competencies annually. 

A core competency assessment was 

developed, and all RNs are assessed 

on an annual basis. 

Y N 

Medication Management 

14. Define a timeframe for PRN11 pain 

medication effectiveness documentation, 

and monitor compliance. 

Policy now defines a timeframe for 

documentation of PRN pain medication 

effectiveness. Compliance is 

monitored by nurse managers. 

Y N 

15. Require that interventions to improve 

patients’ responses to pain medication are 

documented. 

Actions taken when PRN medication is 

not effective are documented. Nurse 

managers review medical records for 

compliance. 

Y N 

16. Require nurse managers to monitor 

compliance with pain scale assessment 

documentation. 

Compliance data extracted daily then 

forwarded to respective nurse 

managers monthly. Quarterly report 

submitted to Quality Council. 

Y N 

COC 

17. Ensure that discharge medications are 

listed on all discharge summaries. 

Discharge summary template now 

includes placeholder for listing 

discharge medications. 

Y N 

11 PRN stands for pro re nata and is commonly used in medicine to mean “as needed.” 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

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 * * * * 59.6 59.5 62.2 62.7 

VISN 69.3 69.6 64.1 63.1 61.0 61.1 62.7 61.6 

VHA 63.3 63.9 64.5 63.8 54.7 55.2 54.8 54.4 

* Numbers too low to report. 

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. 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: May 20, 2011 

From: VISN Director 10N1 

Subject: CAP Review of the Northampton VA Medical Center, 

Leeds, MA 

To: Director, Bedford Office of Healthcare Inspections (54BN) 

Director, Management Review Service (VHA CO 10B5 Staff) 

I have reviewed the findings and recommendations and concur. Our 

actions to the recommendations are attached. 

Michael Mayo-Smith, MD, MPH 

Network Director 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: May 20, 2011 

From: Director, Northampton VA Medical Center 

Subject: CAP Review of the Northampton VA Medical Center, 

Leeds, MA 

To: Director, VA New England Healthcare System (10N1) 

We concur with the recommendations and have already initiated 

corrective actions. 

If you have any questions regarding our responses and actions to the 

recommendations in the draft report, please contact me at 

(413) 582-3000. 

Roger Johnson 

Director 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

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 the Quality Council include the active 

participation of all required members of senior leadership. 

Concur 

Target date for completion: July 31st, 2011 

The Medical Center policy (Quality Council) has been amended to reflect Senior 

Leadership membership in compliance with the national directive. 

Recommendation 2. We recommended that the Quality Council establish a process to 

prioritize PI projects. 

Concur 

Target date for completion: July 31st, 2011 

The Medical Center policy (Quality Council) has been amended to include a 

prioritization process of performance improvement projects. 

Recommendation 3. We recommended that processes be strengthened to ensure that 

QM committees consistently implement action items, track open action items to 

completion, monitor the effectiveness of implemented actions, and modify ineffective 

actions. 

Concur 

Target date for completion: Recommend this item be closed. 

A new minute format which includes assigned action items and completion tracking was 

developed in Feb 2011. Targeted training was provided to Committee chairpersons and 

recorders. Minutes’ format and educational material has been made available to all 

employees on the intranet site. Discussion also occurred at the April Quality Council 

meeting. All major committees are currently utilizing new format. 

Recommendation 4. We recommended that the PRC be notified when corrective 

actions are completed. 

Concur 

Target date for completion: Recommend this item be closed. 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

The Peer Review Committee is notified by service lines when corrective actions for 

Level 2 and Level 3 findings have been completed. Written notification to providers 

through the Service Line Manager currently occurs for all Level 2 and Level 3 findings. 

This includes the corrective action plan. The Local Service Line Managers sign and 

return this document when the actions are completed; this is attached to the Peer 

Review minutes. Effective May, 2011, minutes have been revised to reflect that actions 

have been completed. 

Recommendation 5. We recommended that FPPEs be completed for all physicians 

who have been newly hired or have added new privileges. 

Concur 

Target date for completion: August 5th, 2011 

The two outstanding FPPE noted during the CAP survey have been completed and will 

be reviewed at the Credentialing and Privileging Committee meeting on May 10, 2011. 

Beginning at the April C&P Committee meeting, status of FPPE completion for newly 

hired physicians and those adding new privileges are reported by the Credentialing 

Coordinator at C&P Committee meetings and noted in the minutes to ensure 

appropriate follow up. 

Recommendation 6. We recommended that C&P Committee meeting minutes reflect 

sufficient discussion of the performance data used to make privileging and reprivileging 

decisions. 

Concur 

Target date for completion: August 5th, 2011 

The Credentialing and Privileging Committee minute process was revised to reflect 

discussion of performance data used to make privileging and re-privileging decisions. 

Quality Management will monitor minutes for compliance. 

Recommendation 7. We recommended that local policy for management of advance 

care planning/advance directives be updated to be consistent with current VHA policy 

and that compliance with the updated policy be monitored. 

Concur 

Target date for completion: September 1st, 2011 

At the April 2011 Quality Council meeting, a multi-disciplinary team was appointed to 

revise the local policy and to ensure compliance with VHA Handbook 1004-02 Advance 

Care Planning and Management of Advance Directives. Monitoring for compliance will 

be effected through the Medical Records Committee. 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

Recommendation 8. We recommended that normal test results be consistently 

communicated to patients within the specified timeframe and that the communication 

process be periodically monitored for effectiveness. 

Concur 

Target date for completion: September 1st, 2011 

A multi-disciplinary task group was formed to ensure patient notification of normal test 

results as defined in VHA Directive 2009-019 and to develop monitoring process. 

Specific strategies in process include: review of sample of tests completed in 

March 2011 by service lines to establish baseline performance; identification of best 

practices used by other facilities; develop facility policy that is in compliance with VHA 

Directive 2009-019; staff education of requirements and service line roll out; initiate 

periodic monitoring of this process. 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

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 Jeanne Martin, PharmD, Project Leader 

Frank Keslof, MHA, Team Leader 

Annette Acosta, RN 

Elaine Kahigian, RN, JD 

Claire McDonald, MPA 

Clarissa Reynolds, MBA 

Lynn Sweeney, MD 

Matthew Kidd, Special Agent, Office of Investigations 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the Northampton VA Medical Center, Leeds, MA 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA New England Healthcare System (10N1) 

Director, Northampton VA Medical Center (631/00) 

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: Scott P. Brown, John F. Kerry 

U.S. House of Representatives: Richard E. Neal 

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

VA OIG Office of Healthcare Inspections 18