Report No. 10-01175-91 February 16, 2011

VA Office of Inspector General 

Washington, DC 20420 

Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Alleged Imminent Danger to Patients 

Southern Arizona VA Health Care System 

Tucson, Arizona 
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) 
Alleged Imminent Danger to Patients, Tucson VA Medical Center, Tucson, AZ 

Executive Summary 

The Office of Inspector General received a complaint that alleged unsafe care and 

imminent danger to patients who receive care at the Primary Care Clinics at the Southern 

Arizona VA Health Care System in Tucson, Arizona (the facility). The allegations 

included unsafe triage and handoff of patients from the Emergency Department (ED), 

inadequate clinical support staff, unsafe patient panel sizes, and other quality of care 

issues. 

We did not substantiate that patients in Primary Care (PC) were in imminent danger 

however we did identify opportunities for improvement in clinic operations. The facility 

had experienced significant turnover among Primary Care Providers (PCPs) that resulted 

in reassignment of patients to the remaining PCPs who felt overwhelmed with their panel 

sizes and unsupported by management. Also, there were limited treatment options for 

patients with chronic pain issues and care was often not coordinated. The facility met 

with the PCPs and acknowledged their concerns. The facility’s Systems Redesign 

Committee has begun to undertake changes. 

We substantiated that there was unsafe triage of patients in the ED. ED staff did not 

always evaluate every patient before discharge as required by policy. The facility utilized 

the Emergency Nurses Association’s Emergency Severity Index (ESI) for triage. The ESI 

allows the triage nurse to judge how long patients can wait to be seen by a provider, with 

level 1 as the most urgent and level 5 the least. ED staff sometimes sent ESI 4 and 5 

patients for a second screening in PC where they were given appointments to be seen by a 

provider at a later date. 

We did not substantiate that patients received renewal of narcotic and non-narcotic 

prescriptions without proper assessment. However, we noted opportunities for 

organizational improvement in the care of patients with chronic pain. The facility has 

taken appropriate action to provide support to the PCPs by following the Patient Aligned 

Care Team (PACT) recommendations as well as the guidance provided by the VHA 

National Pain Management Strategy group. 

We did not substantiate that clinical staff was inadequate in PC, that consultants were 

placing orders under the PCP’s name without notification or consent of the provider, or 

that inadequate number of providers resulted in poor patient follow-up, unsafe patient 

panel sizes, unassigned patients, and practitioners being forced to work long hours and 

from home. 

The VISN and facility Directors agreed with our findings and recommendations. The 

implementation plans are acceptable, and we will follow up on the planned actions until 

they are completed. 

VA Office of Inspector General i 
Alleged Imminent Danger to Patients, Southern Arizona VA Health Care System, Tucson, AZ 

DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

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

SUBJECT: Healthcare Inspection– Alleged Imminent Danger to Patients, Southern 

Arizona VA Health Care System, Tucson, Arizona 

Purpose 

The VA Office of Inspector General (OIG) Office of Healthcare Inspections (OHI) 

received allegations of unsafe care and imminent danger to patients at the Southern 

Arizona VA Health Care System, Tucson, Arizona. The purpose of this investigation 

was to evaluate the merit of the allegations. 

Background 

The Southern Arizona VA Health Care System, part of the VA Southwest Health Care 

Network (Veterans Integrated Service Network [VISN] 18), includes the Tucson VA 

Medical Center in Tucson, Arizona. The facility is a tertiary facility that provides a 

broad range of inpatient and outpatient health care services. 

On December 10, 2009, a complainant contacted the OIG hotline with allegations of 

unsafe care and imminent danger to patients who receive care at the Primary Care clinics. 

Specific allegations included the following: 

• Unsafe handoff of patients from the Emergency Department. 

• Unsafe triage of patients. 

• Inadequate clinical support staff. 

• Renewal of narcotic and non-narcotic prescriptions without appropriate patient 

assessment. 

• Ordering tests under the providers name without notification or consent of the 

provider. 

• Inadequate numbers of providers to allow for timely patient follow up. 

• Unsafe patient panel sizes. 

• Thousands of unassigned patients who do not have a provider. 

VA Office of Inspector General 1
Alleged Imminent Danger to Patients, Southern Arizona VA Health Care System, Tucson, AZ 

VA Office of Inspector General 2

• Practitioners forced to work long hours and work from home to keep up with the 

assigned work load. 

Scope and Methodology 

We reviewed pertinent documents, including Veterans Health Administration and facility 

policies and procedures, The Joint Commission standards, committee meeting minutes, 

quality management documents, and medical records. 

We conducted a site visit February 16-18, 2010, interviewing medical care professionals 

to gain further understanding of the issues. We interviewed the Chief of Staff (COS), the 

Chief of Primary Care, the Director of the Emergency Department, the Chief of the 

Pharmacy Care Line, the Pain Clinic Coordinator, the Chief of Information and 

Technology, and others knowledgeable about the issues. 

For insights into critical interactions between the ED and PC clinic, we visited both 

departments and interviewed staff. We reviewed the records of patients seen by the ED 

triage nurse and referred to PC and examined the 364 notes for patient encounters entered 

by five PC triage nurses during October 15-19, 2009. Finally, we examined provider 

panel sizes, ancillary staffing levels, documentation about unassigned patients, and PCP 

notes for evidence of after-hours activity. 

To assess the appropriateness of care for patients prescribed narcotics, we identified all 

outpatients prescribed oxycodone, hydrocodone, and morphine during February 2010. 

After accounting for the relative potency of each medication and for the number of pills 

dispensed, we identified the patients who had received the largest overall amounts of 

narcotics.1

 For each of these patients we examined medical records to evaluate 

comprehensiveness and coordination of care. 

We conducted the inspection in accordance with Quality Standards for Inspections

published by the President’s Council on Integrity and Efficiency.

Findings 

Issue 1. Imminent Danger to patients in Primary Care 

We did not substantiate this allegation, but did identify opportunities for improvement in 

clinic operations. 

PCPs expressed frustration with management’s lack of response to concerns. For several 

years the facility had experienced significant turnover among PCPs, requiring that 

patients be reassigned to new providers. Because they frequently had to evaluate new 

 

1

 Katz NP, et al. Managing Chronic Pain with Opioids in Primary Care. Newton, MA: Inflexxion, Inc.; 2007:59 

(Appendix 15). 
Alleged Imminent Danger to Patients, Southern Arizona VA Health Care System, Tucson, AZ 

patients, PCPs reported feeling overwhelmed and unsupported by management, with 

what they described as unreasonable demands on their time. 

Providers also expressed frustration with their inability to schedule return visits for their 

patients, many of whom required narcotics for chronic pain. There was no specialist 

physician in the Pain Management Clinic and patients referred for pain management 

consultations were often placed on a waiting list. For many patients, treatment options 

were limited, long-term patient-provider relationships were difficult to establish and 

maintain, and care was often not coordinated. 

Providers stated that multiple attempts to address concerns with management were 

unsuccessful. In December 2009, several PCPs signed a statement declaring that in their 

professional opinion patient care provided by the facility was unsafe and that a condition 

of imminent danger existed. 

We the undersigned Primary Care providers at the Southern Arizona VA 

Health Care System, Tucson, Arizona, hereby declare that a condition of 

Imminent Danger exists in the treatment and delivery of care to patients 

treated in Primary Care at the Tucson, VA. We declare that a danger exists 

which could reasonably be expected to cause death or serious physical harm 

immediately or before the imminence of such danger can be eliminated 

through normal procedures. 

By the time of our site visit in February 2010, the facility had met with PCPs and 

acknowledged their concerns, and a Systems Redesign Committee had begun to 

undertake changes. Senior management confirmed an understanding of the challenges 

inherent in recruiting and retaining PCPs, and expressed a commitment to ensuring open 

communication and necessary support. 

Although we made exhaustive inquiries to discover any examples of imminent danger to 

patients, we found no evidence to support this allegation. We considered management’s 

actions to address the identified issues to be appropriate. 

Issue 2. Unsafe triage of patients in the Emergency Department 

We substantiated this allegation. 

We interviewed staff in the ED and in PC to understand processes for the care of 

unscheduled patients presenting to the facility. Patients may seek unscheduled access 

through the ED, PC Clinics, and the Urgent Care Clinic. 

In the process of evaluating the relationship between ED and PC, we discovered that the 

ED was using an accepted triage system, but was applying it incorrectly. 

VA Office of Inspector General 3
Alleged Imminent Danger to Patients, Southern Arizona VA Health Care System, Tucson, AZ 

VA Office of Inspector General 4

VHA requires RN triage in all EDs consistent with an Emergency Nurses Association 

position statement dated July 1996, which entails the use of the Emergency Severity 

Index (ESI) for triage. 2

 The ESI triage algorithm yields rapid, reproducible, and 

clinically relevant stratification of patients into five groups. The ESI triage system 

identifies patients with complex problems (ESI 1-2) and allows the triage nurse to judge 

how long patients can wait to be seen by a provider. Resource prediction is an integral 

part of the ESI level 3, 4, or 5 and is used to determine resources needed to make a 

disposition for the patient. Interventions considered to be resources for the purpose of 

ESI triage are those that go beyond physical examination or brief intervention by ED 

staff. Resources that require significant ED staff time (such as intravenous medication 

administration or chest tube insertion) and those that require staff or resources outside the 

ED (such as specialty consultations and x-rays) increase the patient's ED length of stay. 

Resource prediction is of particular relevance for lower-acuity patients, who are typically 

judged to be ESI levels 4 or 5. These patients may require only limited attention by 

professional staff. However, according to policy, the ED must never discharge a patient 

before a medical assessment has been performed, in accordance with the provisions of 

title CFR 489.24, 489.20.3

At the facility, ESI 4 and 5 patients were sometimes sent for a second screening in PC. 

This second screening employed the Briggs triage system, an approach developed for 

telephone advice, with recommendations to patients about when to seek medical 

attention.4

 A key difference between ESI and Briggs is that the latter allows for care to 

be provided on a subsequent day, depending on patient symptoms. In contrast, the ESI 

assumes that the patient will be seen by an ED or Urgent Care provider during the same 

visit. 

One ED nurse reportedly told patients that they would be waiting a long time to be seen, 

and that patients decided if they wanted to wait or not; however, we found no 

documentation of these interactions and none was provided. Likewise, we found no 

evidence that patients presenting to the ED were advised to wait for an evaluation before 

being given an appointment for a PC clinic visit on a subsequent day. At the time of our 

visit this issue was being examined by the facility’s Systems Redesign Committee. 

In the course of this inspection, we noted that the Urgent Care Clinic, which is located in 

the PC clinic and is staffed by a Nurse Practitioner (NP) with no assigned panel of 

patients, did not meet VHA policy criteria for designation as an Urgent Care Clinic.5

 

2

 VHA Handbook 1101.05, Emergency Medicine Handbook, May 12, 2010. 3 Emergency Medical Treatment and Labor Act, The Center for Medicare/Medicaid. 4 Telephone Triage Protocols for Nurses, 3rd Edition, Julie K. Briggs, Lippincott 2002. 5

 Directive 2007-043, Standards for Nomenclature and Operations for Urgent Care Clinics in VHA Facilities, 

December 18, 2007. 
Alleged Imminent Danger to Patients, Southern Arizona VA Health Care System, Tucson, AZ 

VA Office of Inspector General 5

Issue 3. Inadequate clinical support staff 

We did not substantiate that there was inadequate clinical support staff in the primary 

care clinics. Staffing levels were consistent with national guidelines. Staffing is 

determined by the use of support staff ratio which is the number of full time employee 

(FTE) staff present in the clinic area assisting providers with delivery of PC per 1.0 FTE 

provider.6

Physicians, NPs and physician assistants (PAs) comprise the range of clinicians who 

provide comprehensive primary care to a panel of assigned patients.7

 We interviewed all 

types of PCPs, including those working at the facility for years as well as providers who 

were new in January 2010. 

Providers who had recently worked outside VA did not agree that the clinics were 

understaffed. However, NPs expressed frustration with how they were treated by support 

staff, reporting that nurses would sometimes only assist physicians. Several NPs also 

stated that support staff was not being effectively utilized. They believed that support 

staff could carry out more administrative tasks for providers, such as making follow-up 

phone calls to patients. Finally, medical providers expressed dissatisfaction with the 

functional layout of the PC clinics, indicating that patient flow was impeded by a lack of 

optimally configured space for patient assessment and examination. 

Management, including the COS, Chief of PC Services, and the Associate Director, 

acknowledged that even if the numbers of support staff were sufficient, there might be 

ways to improve how staff function and minimizes administrative demands on PC 

providers.

Issue 4. Renewal of narcotic and non-narcotic prescriptions without 

proper patient assessment. 

We did not substantiate this allegation. However, we noted opportunities for 

organizational improvement in the care of patients with chronic pain. 

Providers described having insufficient time and support to adequately assess patients 

requesting narcotics. Some providers voiced the need for all patients with chronic pain to 

be assigned to the Pain Management Team, which would prescribe and monitor all 

narcotics. Other providers stated an understanding that they were responsible for pain 

management for all their patients. The COS and Chief of PC Services confirmed that 

providers have ultimate authority for clinical decisions about whether to prescribe a 

 

6

 VHA Handbook 1101.02, Primary Care Management Module (PCMM), April 21, 2009. 7

 VHA Handbook 1101.02, Primary Care Management Module (PCMM), April 21, 2009 
Alleged Imminent Danger to Patients, Southern Arizona VA Health Care System, Tucson, AZ 

VA Office of Inspector General 6

medication, acknowledging that some clinicians are more comfortable than others with 

the requirements of patients with complex medical problems and chronic pain.

Our review of the care provided for the patients with the 20 largest prescriptions for 

selected narcotics during February 2010 revealed no evidence that narcotics were being 

prescribed without adequate assessments. The 17 men and 3 women whose care was 

reviewed had a median age of 57 (range, 36-67). Fourteen of these patients had chronic 

low back pain and the remainder had other musculoskeletal problems. Fifteen of the 

patients had been evaluated by pain management consultants. Three patients, two of 

whom had not been evaluated by pain consultants, had received narcotics prescriptions 

from more than three different providers during the previous year. 

VHA has promulgated two approaches pertinent to the management of chronic pain by 

PCPs. The PACT (Patient Aligned Care Team) model is a patient-driven, team-based 

approach for delivering efficient, comprehensive, and continuous care.8

 One of the goals 

of the PACT Model is to facilitate integration of chronic pain management seamlessly 

into PC practice sites. A second goal is to expand educational resources available to PC 

providers on management of chronic pain. A third goal is to initiate systems redesign 

projects to address controlled substance prescriptions written for chronic pain. 

 

The VHA National Pain Management Strategy provides guidance to facilities for the use 

of a steppedcare model of pain management, with most pain care occurring in the PC 

setting.9

 This guidance calls for support for PCPs through access to consultations, 

diagnostic and rehabilitation services, education programs, collaboration with integrative 

mental health-PC teams, and post-deployment programs. 

 

Issue 5. Ordering of tests under a provider’s name without notification 

or consent of the provider. 

We did not substantiate that providers or nurses were ordering tests using PCP names 

without notification or consent. However, we did substantiate that consultants were 

placing orders for primary care patients with the expectation that PCPs would followup 

on test results. 

Medical providers alleged that consultants expected PCPs to followup on the results of 

tests consultants had ordered for patients. Local parameters for the electronic medical 

record had been set so that PCPs received a notification anytime a test result became 

available for an assigned patient, with the understanding that PCPs were responsible for 

all actions in response to results. Non-PCP clinicians were not uniformly expected to 

followup on tests that they ordered. This arrangement created frustration among PCPs 

8

 VHA Primary Care Program Office web site, accessed March 29, 2010. 9

 VHA Directive 2009-053, Pain Management, October 28, 2009. 
Alleged Imminent Danger to Patients, Southern Arizona VA Health Care System, Tucson, AZ 

VA Office of Inspector General 7

and discord with specialists. We learned that PCPs had complained to management about 

the situation. 

In response to these concerns, the Systems Redesign Committee had been created. At the 

time of our visit PCPs reported recent improvement. We were informed that all facility 

providers were reminded that the practitioner who places an order for testing is 

responsible for follow-up of results.10

Issue 6. Inadequate number of providers resulting in poor patient 

follow-up, unsafe patient panel sizes, unassigned patients, and 

practitioners being forced to work long hours and from home. 

We did not substantiate these allegations. 

We found no evidence of inadequate PCP staffing, unsafe patient panel sizes, or an 

excessive number of unassigned patients. 

Medical providers stated that the number of electronic clinical reminders (view alerts), 

that they received forced them to work long hours and work from home to keep up with 

the work load. A clinical reminder is a software decision support tool that can advise 

clinicians to perform certain tests or provide treatments appropriate for specific 

populations. 

Our review of PCP progress notes revealed no indication that providers were routinely 

working outside of normal business hours. 

Recommendations 

Recommendation 1. We recommend that the Director ensures that the facility employs 

the ESI triage system according to VHA policy. 

Recommendation 2. We recommend that the Director ensures that patients who present 

to the facility’s Emergency Department are evaluated by a medical provider and that the 

encounter is documented, before the patient is given a clinic appointment on a later date. 

 

10 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009. 
Alleged Imminent Danger to Patients, Southern Arizona VA Health Care System, Tucson, AZ 

VA Office of Inspector General 8

Comments 

The VISN and facility Directors agreed with our findings and recommendations. The 

implementation plans are acceptable, and we will follow up on the planned actions until 

they are completed 

 (original signed by:) 

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

Assistant Inspector General for

Healthcare Inspections 
Alleged Imminent Danger to Patients, Southern Arizona VA Health Care System, Tucson, AZ 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 9

Department of 

Veterans Affairs Memorandum

Date: January 5, 2011 

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

Subject: Healthcare Inspection- Imminent Danger to Patients, Southern 

Arizona VA Health Care System, Tucson, Arizona 

 To: Director, Management Review Service (10B5) 

I concur with the facility response to the recommendations contained 

in the Healthcare Inspection report. Please see Medical Center 

Director’s comments for specific actions. For questions, please 

contact Sally Compton, Executive Assistant to the Network Director, 

VISN 18, at 602.222.2699. 

(original signed by:)

Susan P. Bowers 

cc: 

Office of Management and Administration, Operational 

Support Division (53B) 

Associate Director, Seattle Regional Office of Healthcare 

Inspections (OIG) 
Alleged Imminent Danger to Patients, Southern Arizona VA Health Care System, Tucson, AZ 

Appendix B 

Medical Center Director Comments 

VA Office of Inspector General 10

Department of 

Veterans Affairs Memorandum

Date: December 29, 2010 

From: Director, Southern Arizona VA Health Care System (678)

Subject: Healthcare Inspection-Imminent Danger to Patients, Southern 

Arizona VA Health Care System, Tucson, Arizona 

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

1. The Southern Arizona VA Health Care System concurs with the 

findings and recommendations from the above healthcare inspection. 

2. Please find attached our reponse to the recommendations provided in 

the report. 

3. If you have any question regarding the response to the recommendations 

in the report, please contact me at (520) 629-1821. 

 (original signed by:) 

Jonathan H. Gardner, FACHE 
Alleged Imminent Danger to Patients, Southern Arizona VA Health Care System, Tucson, AZ 

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 recommend that the Director ensures that the facility 

employs the ESI triage system according to VHA policy. 

Concur 

While the facility has employed the Emergency Severity Index (ESI) 

triage system in the Emergency Room, patients who had minor 

complaints, such as a common cold and an ESI score of 4 or 5 were then 

seen by an RN and given the option to wait to be seen in the ED or 

given an appointment in primary care clinic. This process has been 

terminated effective December 8, 2010. All patients are now seen by a 

provider in the ED. 

Audits will be conducted monthly to assure compliance.

Recommendation 2. We recommend that the Director ensures that 

patients who present to the facility’s Emergency Department are evaluated 

by a medical provider and that the encounter is documented, before the 

patient is given a clinic appointment on a later date. 

Concur 

Effective December 8, 2010, patients who present to the facility’s 

Emergency Department (ED) are evaluated by a medical provider and 

the encounter is documented. All patients are now seen by a medical 

provider in the ED. 

Audits will be conducted monthly to assure compliance. 

VA Office of Inspector General 11
Alleged Imminent Danger to Patients, Southern Arizona VA Health Care System, Tucson, AZ 

Appendix C 

OIG Staff 

OIG Contact Gail Bozzelli, RN 

Seattle Office of Healthcare Inspections 

Jerome Herbers, MD 

VA Office of Inspector General 12
Alleged Imminent Danger to Patients, Southern Arizona VA Health Care System, Tucson, AZ 

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, Southern Arizona VA Health Care System (678) 

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: John McCain, Jon Kyl 

U.S. House of Representatives: Gabrielle Griffords, Raul Grijalva 

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

VA Office of Inspector General 13