Department of Veterans Affairs
	

Office of Inspector General
	

Healthcare Inspection
 

Customer Care and Satisfaction
 

Southern Arizona VA Health Care System
 

Tucson, Arizona
 

Report No. 11-00233-137 March 31, 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)
 
Customer Care and Satisfaction, Southern Arizona VA Health Care System, Tucson, Arizona 

Executive Summary
	

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

inspection to determine the validity of allegations regarding customer care and

satisfaction at the Casa Grande Community Based Outpatient Clinic (CBOC) in Casa

Grande, AZ. The CBOC is part of the Southern Arizona VA Health Care System in

Tucson, AZ.

The complainants specifically alleged that:

	 A licensed practical nurse (LPN) took a patient’s vital signs, did not document the

patient’s vital signs in the medical record, and then referred the patient to a local

emergency room (ER).

	 A provider did not appropriately examine two patients; CBOC front desk staff and

management harass and treat patients rudely.

	 There are increased complaints from patients regarding telephone wait times of up

to 45 minutes to speak with pharmacy representatives.

	 CBOC staff are harassing a patient by intercepting the patient’s calls to CBOC

providers or that the patient is out of pain medication and has been abandoned

because of a lack of returned phone calls from the patient’s primary care physician

(PCP) and psychiatrist.

We substantiated that a patient presented to the CBOC for evaluation of bleeding and an

LPN took the patient’s vital signs but did not document them in the medical record. We

did not substantiate that the LPN referred the patient to a local emergency room, that

two patients received inappropriate examinations, that CBOC staff harassed or treated

patients rudely, or that patient complaints regarding long telephone wait times to speak

with pharmacy representatives had increased.

We did not substantiate that CBOC staff continue to harass a patient complainant or that

providers have abandoned this patient. Mental health providers saw the patient

twice since our onsite visit, and future appointments are scheduled with the CBOC

psychiatrist. The patient also saw the CBOC PCP since our onsite visit and has future

appointments scheduled. The patient’s PCP has documented interventions regarding

management of the patient’s pain and there are multiple notes documenting telephone

interactions between the patient and CBOC Mental Health and Social Work Service

providers.

We made no recommendations.

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 – Customer Care and Satisfaction, Southern

Arizona VA Health Care System, Tucson, Arizona

Purpose 

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

reviewed allegations regarding customer care and satisfaction at the Casa Grande

Community Based Outpatient Clinic (CBOC) in Casa Grande, AZ. The purpose of the

inspection was to determine if the allegations had merit.

Background 

The CBOC is part of the Southern Arizona VA Health Care System (facility) in Tucson,

AZ. The CBOC provides outpatient primary care services to approximately 3,000 unique

veterans.

The facility provides acute care for veterans with inpatient and outpatient health care

services. It is part of Veterans Integrated Service Network 18 and serves a patient

population of about 173,000. The facility provides outpatient care at seven CBOCs

located in Northwest Tucson, Southeast Tucson, Casa Grande, Green Valley, Safford,

Sierra Vista, and Yuma, AZ.

In October 2010, two complainants contacted OIG’s Hotline Division regarding customer

care and satisfaction issues at the CBOC. The complainants specifically alleged that:

	 A licensed practical nurse (LPN) took a patient’s vital signs, did not document the

patient’s vital signs in the medical record, and then referred the patient to a local

emergency room (ER).

	 A provider did not appropriately examine two patients for their complaints.

VA Office of Inspector General 1 
Customer Care and Satisfaction, Southern Arizona VA Health Care System, Tucson, Arizona 

	 CBOC front desk staff and management harass and treat patients rudely.

	 There are increased complaints from patients regarding telephone wait times of up

to 45 minutes to speak with pharmacy representatives.

In January 2011, one of the complainants contacted OIG’s Hotline Division regarding

additional complaints about the harassment and abandonment of one of the patients in the

original complaint. Specifically, the complainant alleged that:

	 CBOC staff are harassing a patient by intercepting the patient’s calls to CBOC

providers, and the intended recipient of the call does not return the call.

	 The patient is out of pain medication and has been abandoned because of a lack of

returned phone calls from the patient’s primary care physician (PCP) and

psychiatrist.

Scope and Methodology 

We interviewed the complainants by telephone prior to our site visit of the facility and

CBOC on November 16–17, 2010. We also interviewed four of the five patients listed by

one of the complainants as having relevant experiences at the CBOC. While onsite, we

interviewed managers, clinicians, and other employees with key knowledge of the

complaints. We reviewed facility and VHA policies, relevant medical records, and all

CBOC patient complaints and customer feedback from October 1, 2009, through

September 30, 2010.

One of the complainants made allegations that were beyond the scope of an OHI review.

These allegations concerned labor relation and equal employment opportunity issues.

This review focused on the allegations directly related to patient care and satisfaction.

We conducted the inspection 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: Customer Care 

We substantiated that a patient came to the CBOC for evaluation of bleeding, an LPN

took the patient’s vital signs, and the LPN did not document the patient’s vital signs in

the medical record. We did not substantiate that the LPN referred the patient to a local

ER for treatment. We interviewed the patient and CBOC management and reviewed the

patient’s medical record. A registered nurse (RN) documented the interaction with the

patient. The RN suggested that the patient go to a local ER or to the Tucson ER for

evaluation. The patient’s medical record did not contain vital signs obtained during the

VA Office of Inspector General 2 
Customer Care and Satisfaction, Southern Arizona VA Health Care System, Tucson, Arizona 

encounter. By standard operating procedure (SOP) for patient triage,1 an LPN may

obtain patient vital signs; however, an RN is responsible for medical record

documentation. The RN did not follow SOP and document the patient’s vital signs in the

medical record. CBOC management addressed the failure of the RN to follow SOP prior

to our review.

We did not substantiate the allegation that a provider did not appropriately examine

two patients for their complaints. We interviewed the two patients and reviewed their

medical records. One of the patients reported that a provider failed to perform a foot

exam during a clinic visit in December 2007 despite a diagnosis of diabetes; however, the

patient’s medical record documents a foot exam was performed during that visit. The

second patient disagreed with the complainant and denied having inappropriate

examinations at the CBOC.

Issue 2: Customer Service 

We did not substantiate the allegation that CBOC staff harassed or treated patients rudely.

We interviewed four of the five patients who reported CBOC customer service issues to

one of the complainants, facility leadership, and CBOC management and staff. We

reviewed all written CBOC patient complaints from October 1, 2009, through

September 30, 2010, and all customer feedback provided through “Are You Satisfied?”

forms2 from program initiation in March 2010.

Although none of the interviewed patients described being harassed, two of the patients

confirmed feeling rudely treated by CBOC staff as described by the complainant.

However, the complainant did not accurately describe the issues encountered by the other

two patients. One of the patients described an issue with another patient during group

therapy, not with CBOC staff as described by the complainant. The second patient

acknowledged that a CBOC provider made a one-time curt statement, but the patient felt

that the provider was “simply having a bad day” and did not see a need to report it.

Two written complaints filed during our review period for the CBOC concerned staff

courtesy. Facility and CBOC management addressed both complaints prior to our

review. Of the 39 total “Are You Satisfied?” forms submitted during the review period,

38 (97 percent) were complimentary of CBOC staff and services.

We did not substantiate the allegation of increased complaints from patients regarding

telephone wait times to speak with pharmacy representatives. For our review period,

there were no complaints specific to pharmacy telephone wait times. Furthermore,

although CBOC staff did not track verbal complaints, they felt the number of verbal

complaints from patients regarding pharmacy telephone waits times had decreased.

Facility leadership also described an ongoing system redesign project implemented in

1 Triage is the process of determining the priority of patients' treatments based on the severity of their condition. 2 Customer feedback forms are available for patients to fill out about their clinic visit.

VA Office of Inspector General 3 
Customer Care and Satisfaction, Southern Arizona VA Health Care System, Tucson, Arizona 

early 2010 that reduced the pharmacy call volume and associated wait times to reach

pharmacy representatives.

Issue 3: Additional Allegations of Patient Care 

We did not substantiate the additional allegations that CBOC staff continue to harass the

patient complainant or that providers have abandoned this patient.

Clinic staff handle all telephone calls that come into the CBOC for providers. Providers

return calls as time allows during the workday. CBOC mental health (MH) providers and

the PCP have documented that they have seen and spoken with the patient several times

since our onsite visit.

During a return call from the CBOC MH social worker, the patient had an outburst of

inappropriate language and made threats toward staff. The social worker followed

protocol by filling out a behavior incident report and reporting the incident to the police.

However, this did not affect his treatment. There is documentation of scheduled

follow-up appointments for pain, mental health, and primary care; and there are current

active prescriptions for medications that will provide enough medications until the

patient’s next appointment.

The PCP has documented discussions with the patient about pain management. The

patient has been seen by physical therapy, had pain medication adjusted, and a consult

was sent for the patient to be seen in the chronic pain management clinic. The PCP has

made appropriate referrals.

Conclusions 

We did not find evidence of widespread problems related to customer care or satisfaction

at the CBOC. CBOC and facility management promote a patient-centered atmosphere

and take appropriate actions when employees do not meet this expectation.

There is no evidence to suggest that harassment or abandonment by providers occurred

toward the identified patient. The patient was seen several times since our visit, there is

documentation of returned calls to the patient, and the patient has future appointments for

care at the facility.

We made no recommendations.

VA Office of Inspector General 4 
Customer Care and Satisfaction, Southern Arizona VA Health Care System, Tucson, Arizona 

Comments 

The VISN and facility Directors concurred with our findings (see Appendixes A and B,

pages 6–7, for the Directors’ comments). We made no recommendations and plan no

further actions.

 (original signed by:)

 JOHN D. DAIGH, JR., M.D

 Assistant Inspector General for

 Healthcare Inspections 

VA Office of Inspector General 5 
Customer Care and Satisfaction, Southern Arizona VA Health Care System, Tucson, Arizona 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: March 23, 2011
 

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

Subject: Healthcare Inspection – Customer Care and Satisfaction,
 

Southern Arizona VA Health Care System, Tucson, Arizona 

To: Director, Dallas Office of Healthcare Inspections (54DA)

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 6 
Customer Care and Satisfaction, Southern Arizona VA Health Care System, Tucson, Arizona 

Appendix B 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 March 23, 2011

From:	 Director, Southern Arizona VA Health Care System (678/00)

Subject:	 Healthcare Inspection – Customer Care and Satisfaction, 

Southern Arizona VA Health Care System, Tucson, Arizona 

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

1. The Southern Arizona VA Health Care System has

reviewed and concurs with the report regarding your review

of issues at our Casa Grande Community Based Outpatient

Clinic (CBOC) in Casa Grande, AZ.

2. The omission by the CBOC RN to follow the standard

operating procedure for patient triage has been addressed with

the RN as annotated in your report. Professional practice

reviews are occurring to insure appropriate practices.

3. If you have any questions regarding these comments,

please contact me at (520) 629-1821.

(original signed by:) 

Jonathan H. Gardner, MPA, FACHE
 

Director, Southern Arizona VA Health Care System (678/00)
 

VA Office of Inspector General 7 
Customer Care and Satisfaction, Southern Arizona VA Health Care System, Tucson, Arizona 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Cathleen King, RN, Associate Director

Dallas Office of Healthcare Inspections

Acknowledgments Larry Ross, MS, Team Leader

Gayle Karamanos, PA

George Wesley, MD

Misti Kincaid, BS, Program Support Assistant

VA Office of Inspector General 8 
Customer Care and Satisfaction, Southern Arizona VA Health Care System, Tucson, Arizona 

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 (678/00)

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: Jon Kyl, John McCain

U.S. House of Representatives: Trent Franks, Gabrielle Giffords, Raul Grijalva,

Paul Gosar

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

VA Office of Inspector General 9