Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 10-02983-55

Combined Assessment Program
 

Review of the
 

VA North Texas Health Care System
 

Dallas, Texas
 

January 12, 2011
 

Washington, DC 20420
 
Why We Did This Review 

Combined Assessment Program (CAP) reviews are part of the Office of Inspector 

General's (OIG's) efforts to ensure that high quality health care is provided to our 

Nation's veterans. CAP reviews combine the knowledge and skills of the OIG's Offices 

of Healthcare Inspections and Investigations to provide collaborative assessments of 

VA medical facilities on a cyclical basis. The purposes of CAP reviews are to: 

 Evaluate how well VA facilities are accomplishing their missions of providing veterans 

convenient access to high quality medical services. 

 Provide crime awareness briefings to increase employee understanding of the 

potential for program fraud and the requirement to refer suspected criminal activity to 

the OIG. 

In addition to this typical coverage, CAP reviews may examine issues or allegations 

referred by VA employees, patients, Members of Congress, or others. 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CBOC community based outpatient clinic 

CCU critical care unit 

CHF congestive heart failure 

CLC community living center 

COC coordination of care 

CNH contract nursing home 

CPRS Computerized Patient Record System 

ED emergency department 

EOC environment of care 

FTE full-time employee equivalents 

FY fiscal year 

IC infection control 

ICU intensive care unit 

JC Joint Commission 

MDRO multidrug-resistant organisms 

MH mental health 

MICU medical intensive care unit 

OEF Operation Enduring Freedom 

OIF Operation Iraqi Freedom 

OIG Office of Inspector General 

OSHA Occupational Safety and Health Administration 

PR peer review 

PRRTP Psychosocial Residential Rehabilitation Treatment 

Program 

SCI spinal cord injury 

SOP standard operating procedure 

QM quality management 

UM utilization management 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

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
 

EOC................................................................................................................... 4
 

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

Management of MDRO...................................................................................... 5
 

Management of Test Results............................................................................. 6
 

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

Medication Management ................................................................................... 6
 

Physician C&P................................................................................................... 7
 

Comments................................................................................................................... 7
 

Appendixes 

A. Facility Profile .................................................................................................... 8
 

B. Follow-Up on Previous Recommendations........................................................ 9
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 14
 

D. VISN Director Comments .................................................................................. 16
 

E. Interim Facility Director Comments.................................................................... 17
 

F. OIG Contact and Staff Acknowledgments ......................................................... 21
 

G. Report Distribution ............................................................................................ 22
 

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

Review of the VA North Texas Health Care System, Dallas, TX 

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 

October 18, 2010. 

Review Results: The review covered 

seven activities. We made no 

recommendations in the following 

activities: 

	 Medication Management 

	 Physician Credentialing and 

Privileging 

The facility’s reported accomplishments 

included the development of an 

electronic medical records review 

database adopted by 20 Veterans 

Health Administration (VHA) facilities 

and the facility’s first place Fiscal Year 

2010 Systems Redesign Champion 

award for Inpatient Systems Redesign. 

Recommendations: We made 

recommendations in the following five 

activities: 

Quality Management: Ensure that all 

peer reviews are completed within the 

120-day timeframe or have an extension 

requested that is approved in writing by 

the Director. Require that 

unauthenticated documentation is 

monitored in accordance with VHA 

policy. 

Environment of Care: Conduct a 

comprehensive risk assessment to 

address examination tables and sharps 

containers throughout the facility, and 

correct identified deficiencies. 

Coordination of Care: Document 

advance directive notification, and 

document advance care planning using 

approved progress note titles. 

Management of Multidrug-Resistant 

Organisms: Ensure that infection 

strategies education is provided to 

patients infected or colonized with 

multidrug-resistant organisms and their 

families and that the education is 

documented. 

Management of Test Results: Ensure 

that normal results are communicated to 

patients within the specified timeframe. 

Comments 

The VISN and Interim Facility Directors 

agreed with the CAP review findings 

and recommendations and provided 

acceptable improvement plans. 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
 

VA OIG Office of Healthcare Inspections i 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

Objectives and Scope 

Objectives
 

Scope
 

Objectives. 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. 

Scope. 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 

seven activities: 

	 COC 

	 EOC 

	 Management of MDRO 

	 Management of Test Results 

	 Medication Management 

	 Physician C&P 

	 QM 

The review covered facility operations for FY 2010 and 

FY 2011 through October 18, 2010, and was done in 

accordance with OIG SOPs for CAP reviews. We also 

followed up on selected recommendations from our prior 

CAP review of the facility (Combined Assessment Program 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

Review of the VA North Texas Health Care System, Dallas, 

Texas, Report No. 06-03482-86, February 26, 2007). We 

identified two repeat findings in QM. 

During this review, we also presented crime awareness 

briefings for 660 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 

In 2009, staff developed a new database to evaluate and 

audit medical records for completeness. The facility is 

required to evaluate 75 medical records per month, and each 

has numerous areas for review. In order to meet regulatory 

requirements for auditing, staff developed an electronic 

database that automates the reporting process. 

Reports are generated informing providers of opportunities 

for improvement and omissions in the medical record. Staff 

members from every service complete medical record 

reviews, and the information is used by facility managers to 

improve quality and ensure completeness. 

The database was presented to other VHA facilities on a 

national Health Information Management conference call as 

a best practice. To date, 20 other facilities have adopted this 

database. 

The facility received the first place FY 2010 Systems 

Redesign Champion Award for Inpatient Systems Redesign. 

This award was the result of improvements made to the 

management of patient movement from the inpatient to 

outpatient care setting. Managing how patients move 

throughout the facility is an essential part of providing timely, 

quality care. 

Managers implemented daily patient flow huddle meetings on 

the inpatient units, developed a discharge center, and 

redesigned the patient transfer process. Patients are 

assigned discharge appointments, which allows for 

discharges to be distributed throughout the day. Managers 

Electronic Medical 

Records Review 

Database 

VHA Systems 

Redesign Award 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

improved the process of transferring patients into and out of 

the Dallas campus, which has decreased the lengths of stays 

for patients hospitalized on the medical/surgical units and the 

ICUs. As a result of the changes, managers are able to 

optimize the efficiency of facility resources to expeditiously 

accommodate patient needs. 

These system redesign efforts improved quality and access 

to care for patients and resulted in a significant cost 

avoidance of $35 million from 2009 through FY 2010. 

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. Senior managers were very supportive of QM 

program activities. However, we identified the following 

areas that needed improvement. 

PR. Once the need for a PR is determined, VHA requires 

that the final review be completed within 120 days or that an 

extension be requested from and approved in writing by the 

facility’s Director.1 We reviewed the FY 2010 PR database 

and noted that 2 (2 percent) of 93 final PRs exceeded the 

120-day timeframe and that extensions had not been 

requested or approved. This is a repeat finding from our 

previous CAP review. 

Medical Records Review. VHA requires that the ongoing 

medical records review process monitors unauthenticated, 

electronic documentation.2 The following documentation 

must be monitored: (1) lack of notes for outpatient 

encounters3 that exist in VHA information systems; 

(2) unsigned and/or un-cosigned progress notes, addenda, 

discharge summaries, and operative reports; and 

(3) unsigned orders. Unsigned electronic documentation 

cannot be viewed by other clinicians. We found that the 

required documentation was not monitored on a consistent 

1 VHA Directive, 2008-004, Peer Review for Quality Management, January 28, 2008. 2 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 3 An encounter is a professional contact between a patient and a practitioner. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

Recommendations 

EOC 

Recommendation 

basis and that no data existed regarding the lack of notes for 

outpatient encounters. With regards to operative reports and 

post-operative notes, this is a repeat finding from our 

previous CAP review. 

1. We recommended that all PRs be completed within the 

120-day timeframe or have an extension requested that is 

approved in writing by the facility’s Director. 

2. We recommended that unauthenticated documentation 

be monitored in accordance with VHA policy. 

The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

At the Dallas campus, we inspected the SCI, MH, OEF/OIF, 

and Primary Care 3 and 4 clinics; radiology; the ED; the 

CLC; and the SCI, 7A Medicine, 6C Acute Care, MICU, 

CCU, and MH units. At the Bonham campus, we inspected 

the primary care, MH, dental, and specialty clinics; the CLC; 

and radiology. Both campuses maintained a generally clean 

and safe environment. We reviewed employee training 

records for bloodborne pathogens and radiation safety and 

determined that there was overall compliance with required 

training. However, we identified the following conditions that 

needed improvement. 

IC. VHA facilities must employ infection prevention and 

control activities. At the Dallas campus, eight examination 

tables located in two primary care clinics had torn and 

cracked surfaces. Examination tables with compromised 

surfaces may present an IC risk to patients. 

Sharps Containers. OSHA requires that containers for 

needles and other sharp objects are secured, not overfilled, 

easily accessible, puncture resistant, and leak proof. At the 

Bonham campus, there were two unsecured containers and 

three wall-mounted containers that were not easily 

accessible to all staff. 

3. We recommended that a comprehensive risk 

assessment be conducted to address examination tables 

and sharps containers throughout the facility and that 

identified deficiencies be corrected. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

COC
 

Recommendation 

Management of 

MDRO 

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 Directive Notification Documentation. VHA 

requires that patients be given written notification stating 

their right to accept or refuse medical treatment, to designate 

a health care agent, and to document their treatment 

preferences in an advance directive.4 We reviewed 

10 patients’ medical records and found that only 

1 (10 percent) had notification documented. The facility is 

revising their progress note template to incorporate advance 

directive notification. 

Advance Care Planning Progress Note Titles. VHA requires 

that staff use specific progress note titles when documenting 

advance care planning discussions with patients.5 However, 

the facility’s local policy conflicted with this requirement. 

While we were onsite, managers revised the local policy to 

include only approved progress note titles. 

4. We recommended that staff document advance directive 

notification and document advance care planning using 

approved progress note titles. 

The purpose of this review was to evaluate whether the 

facility had developed a safe and effective program to reduce 

the incidence of MDRO in its patient population in 

accordance with applicable requirements. 

We inspected the SCI and medicine units at the Dallas 

campus and the CLC at the Bonham campus, and we 

interviewed five employees. We identified no deficits in 

either the inspections or staff interviews. We reviewed 

42 employee MDRO training records and determined that 

41 (98 percent) had documentation of required training. 

However, we identified the following area that needed 

improvement. 

4 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009. 5 VHA Handbook 1004.02. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

Patient/Family Education. The JC requires that patients 

infected or colonized6 with MDRO and their families receive 

education on infection prevention strategies, such as hand 

washing and the proper use of personal protective 

equipment. We reviewed 17 medical records and found that 

16 (94 percent) of the records did not have documented 

evidence of MDRO education. 

Recommendation	 5. We recommended that infection strategies education be 

provided to patients infected or colonized with MDRO and 

their families and be documented. 

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

Test Results 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. 

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 

only 13 (65 percent) contained documented evidence that 

the facility had communicated the results to the patients. 

Recommendation	 6. We recommended that normal results be communicated 

to patients within the specified timeframe. 

Review Activities Without Recommendations 

Medication	 The purpose of this review was to determine whether the 

Management facility employed safe practices in the preparation, transport, 

and administration of hazardous medications, specifically 

chemotherapy, in accordance with applicable requirements. 

We observed the compounding and transportation of 

chemotherapy medications and the administration of those 

medications in the oncology clinic, and we interviewed 

employees. We determined that the facility safely prepared, 

6 Colonization is the presence of bacteria in the body without causing clinical infection.
 7 Healthcare Inspection Summary Review – Evaluation of Veterans Health Administration Procedures for
 

Communicating Abnormal Test Results, Report No. 01-01965-24, November 25, 2002.
 8 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009.
 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

transported, and administered the medications. We made 

no recommendations. 

Physician C&P	 The purpose of this review was to determine whether the 

facility had consistent processes for physician C&P that 

complied with applicable requirements. 

We reviewed C&P files and profiles and meeting minutes 

during which discussions about the physicians took place. 

We determined that the facility had implemented a consistent 

C&P process that met current requirements. We made no 

recommendations. 

Comments 

The VISN and Interim Facility Directors agreed with the CAP review findings and 

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 16–20 for full text of the Directors’ comments.) We will follow up on the 

planned actions until they are completed. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

Appendix A 

Facility Profile9 

Type of Organization Tertiary care medical center 

Complexity Level 1a 

VISN 17 

CBOCs Bridgeport, TX 

Denton, TX 

Granbury, TX 

Greenville, TX 

Paris, TX 

Sherman, TX 

Veteran Population in Catchment Area Approximately 490,000 

Type and Number of Total Operating Beds: 

 Hospital, including PRRTP 308 

 CLC 196 

 Domiciliary 306 

Medical School Affiliation(s) University of Texas Southwestern Medical 

School at Dallas 

Baylor College of Dentistry 

University of North Texas Health Science 

Center 

Texas Woman’s University 

University of Texas at Arlington 

Texas Tech University 

 Number of Residents Approximately 780 

Current FY (through 

August 2010) 

Prior FY (2009) 

Resources (in millions): 

 Total Medical Care Budget $722.9 $688 

 Medical Care Expenditures $635 $680 

Total Medical Care FTE 3,594.1 3,592.6 

Workload: 

 Number of Station Level Unique 

Patients 

101,587 103,504 

 Inpatient Days of Care: 

o Acute Care 60,877 76,201 

o CLC/Nursing Home Care Unit 51,713 64,283 

Hospital Discharges 9,499 11,700 

Total Average Daily Census (including all bed 

types) 

621.5 650.4 

Cumulative Occupancy Rate 74.06% 77.71% 

Outpatient Visits 1,177,475 1,177,605 

9 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective 

Actions Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM Program 

1. Ensure that a comprehensive, 

effective QM program capable of 

identifying and resolving quality and 

patient safety issues is constructed at the 

facility. The following deficient program 

areas were identified: 

 QM oversight Committee structure and processes 

were realigned to provide effective 

oversight of QM activities. 

Y N 

 Mortality review and analysis The mortality review process was 

revised, and mortality reviews are 

being conducted and analyzed in a 

timely manner. 

Y N 

 Patient safety Root cause analyses are being 

conducted in accordance with VHA 

policy, and required actions have 

been completed for the patient 

safety alerts. 

Y N 

 Data tracking, trending, analysis, 

and reporting 

Data is consistently collected, 

trended, analyzed, and discussed 

in committees; corrective actions 

are developed, implemented, and 

monitored for effectiveness. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

Recommendations Current Status of Corrective 

Actions Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

 PR With the exception of the 

completion of the final review of PR 

cases within the 120-day 

timeframe, the PR process is in 

compliance with VHA policy. 

N Y (see pages 3 

and 4) 

 Adverse event disclosure Clinical disclosure of adverse 

events is in compliance with VHA 

policy. 

Y N 

 Operative reports For FY 2010, there is a high volume 

of delinquent operative reports and 

brief post-operative progress notes. 

N Y (see pages 3 

and 4) 

2. Officially appoint and train the UM 

physician advisor. 

A UM physician advisor has been 

appointed, trained, and certified in 

accordance with VHA policy. 

Y N 

CNH Program 

3. Ensure CNH Program nurses visit 

veterans in contract nursing facilities and 

document veterans’ medical records as 

required. 

Each veteran in a CNH is visited 

every 30 days by a social worker or 

nurse. The visits must be 

documented in CPRS within 

48 hours. The CNH Program 

Coordinator conducts monthly 

audits to monitor compliance rates. 

This information is reviewed by the 

CNH Review Team monthly, the 

Community Nursing Home Advisory 

Committee quarterly, and the 

Quality Council monthly. 

Y N 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

Recommendations Current Status of Corrective 

Actions Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

4. Ensure CNH Program staff increase 

monitoring of contract nursing facilities 

not meeting quality or exclusion criteria 

and document the rationale(s) for 

contract renewal. 

Each CNH is reviewed annually by 

the CNH Review Team and the 

CNH Oversight Committee. This 

review considers the family 

member, website information, 

information from the CNH nurse 

and social worker, and satisfaction 

with the care. 

If a facility does not meet 

exclusionary criteria and its contract 

is renewed, the reasons are clearly 

documented. These facilities are 

placed on an action plan, and 

targeted action items are reviewed 

during meetings until the actions 

have been resolved. 

Y N 

5. Ensure CNH Program staff enter the 

appropriate range of billing codes for 

facility visits. 

CNH Program nurses and social 

workers were trained on 

November 28, 2006, and again on 

April 27, 2010. The CNH Program 

Coordinator reviews billing codes 

during a monthly random audit. 

This information is reviewed by the 

CNH Review Team monthly and the 

CNH Oversight Committee 

quarterly. 

Y N 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

Recommendations Current Status of Corrective In Compliance Repeat 

Actions Taken Y/N Recommendation? 

Y/N 

6. Ensure CNH Program staff follow CNH staff have been trained on Y N 

standard procedures when using a appropriate use of Government 

Government vehicle. vehicles. For staff assigned to the 

facility motor pool, the trip ticket 

system was converted to a travel 

log. Each employee is assigned a 

vehicle and must complete the log 

for each trip. This information is 

provided to Engineering Service 

monthly. 

Staff assigned to the Bonham motor 

pool complete a trip ticket 

requesting a vehicle. They are 

assigned a vehicle for that trip. 

After a trip, staff provide individual 

trip tickets to Engineering Service 

CBOCs 

7. Timely implement CPRS at all CBOCs. All CBOCs have T-1 lines at the 

clinics; thus, all clinics are now 

paperless. 

Y N 

8. Ensure CBOC staff properly secure 

veterans’ medical information. 

All CBOCs are paperless since all 

sites now have T-1 capabilities. 

Y N 

9. Require designated facility staff to 

review the contractor’s annual report for 

all appropriate performance elements. 

Contractor annual reports are 

evaluated as part of the contract 

renewal process. Modifications are 

sent to the clinics for clarification. 

Y N 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

Recommendations Current Status of Corrective 

Actions Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

10. Require designated facility inspection 

team members to follow up on inspection 

deficiencies and assure completion of 

corrective actions. 

QM nursing staff utilize an 

inspection form to record 

deficiencies, which are tracked in a 

database until completion. 

Y N 

Cardiac Catheterization 

11. Require staff to complete informed 

consents for cardiac catheterization 

procedures consistent with VHA policy. 

Informed consent completion is 

monitored weekly through the 

leadership dashboard. 

Catheterization laboratory audits 

demonstrate 100 percent 

compliance. 

Y N 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

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 

quarters 1–3 of FY 2010. 

Table 1 

FY 2010 

(inpatient target = 64, outpatient target = 56) 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 2 

Inpatient 

Score 

Quarter 3 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Outpatient 

Score 

Quarter 3 

Facility 41.9 47.3 58.1 38.7 49.3 46.2 

VISN 52.1 56.0 61.8 46.1 50.5 48.4 

VHA 63.3 63.9 64.5 54.7 55.2 54.8 

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 14 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

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

conditions10 received hospital care. The mortality (or death) rates focus on whether 

patients died within 30 days of their hospitalization. The rates of readmission focus on 

whether patients were hospitalized again within 30 days. Mortality rates and rates of 

readmission show whether a hospital is doing its best to prevent complications, teach 

patients at discharge, and ensure patients make a smooth transition to their home or 

another setting. The hospital mortality rates and rates of readmission are based on 

people who are 65 and older. These comparisons are “adjusted” to take into account 

their age and how sick patients were before they were admitted to the VA facility. 

Table 2 below shows the facility’s Hospital Outcome of Care Measures for 

FYs 2006–2009. 

Table 2 

Mortality Readmission 

Heart Attack CHF Pneumonia Heart Attack CHF Pneumonia 

Facility 13.65 10.13 14.81 22.13 24.21 15.77 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

10 CHF is a weakening of the heart’s pumping power. With heart failure, your body does not get enough oxygen and 

nutrients to meet its needs. A heart attack (also called acute myocardial infarction) happens when blood flow to a 

section of the heart muscle becomes blocked and the blood supply is slowed or stopped. If the blood flow is not 

restored in a timely manner, the sedition of the heart muscle becomes damaged from lack of oxygen. Pneumonia is 

a serious lung infection that fills your lungs with mucus and causes difficulty breathing, fever, cough, and fatigue. 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: December 14, 2010 

From: Director, VA Heart of Texas Health Care Network (10N17) 

Subject: CAP Review of the VA North Texas Health Care System, 

Dallas, TX 

To: Director, Chicago Office of Healthcare Inspections (54CH) 

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

1.	 Attached is the response from the VA North Texas Health Care 

System to the draft report from the Combined Assessment Program 

Review conducted at the facility October 18th–22nd, 2010. 

2.	 The medical center carefully reviewed all items identified as 

opportunities for improvement and has concurred with all 

recommendations. The Network also concurs with the 

recommendations contained in the report. 

3.	 If you have any questions or need additional information, please 

contact Judy Finley, VISN 17 QMO, at (817) 385-3761. 

Lawrence A. Brio 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

Appendix E 

Interim Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: December 14, 2010 

From: Interim Director, VA North Texas Health Care System 

(549/00) 

Subject: CAP Review of the VA North Texas Health Care System, 

Dallas, TX 

To: Director, VA Heart of Texas Health Care Network (10N17) 

1. We appreciate the opportunity to review the draft report 

of the Combined Assessment Program Review completed 

October 18th–22nd, 2010 for the VA North Texas Health Care System in 

Dallas, Texas. 

2. Attached you will find actions for each recommendation. Several of the 

actions have already been initiated. 

3. We would like to extend our appreciation to the entire Office of 

Inspector General Team who was consultative, professional and provided 

excellent feedback to our staff. We appreciate their thorough review and 

the opportunity to further improve the quality care we provide to our 

Veterans every day. 

Shirley M. Bealer 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

Comments to Office of Inspector General’s Report
 

The following Acting, Facility Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General report: 

OIG Recommendations 

Recommendation 1. We recommended that all PRs be completed within the 120-day 

timeframe or have an extension requested that is approved in writing by the facility’s 

Director. 

Concur 

Target date for completion: March 31, 2011 

VA North Texas Health Care System (VANTHCS) Clinical Quality Management, Risk 

Management Section finalized an electronic tracking tool to effectively identify 

significant deadlines including 120-day PR events. This tool is currently being fully 

utilized to manage PR timelines. 

For three months, the Director of Corporate Quality Management and Customer Service 

will conduct monthly reviews of the Risk Management tracking tool to validate 100% 

compliance with prescribed PR 120-day deadlines and completion of extension 

requests. 

Recommendation 2. We recommended that unauthenticated documentation be 

monitored in accordance with VHA policy. 

Concur 

Target date for completion: June 30, 2011 

In accordance with VHA policy, the Health Information Management Section is collating 

weekly medical record reports and identifying unauthenticated documentation 

deficiencies. This data is provided to the Chief of Staff’s Office, Health Information 

Management Committee and Service level leadership for tracking and timely resolution. 

By June 30, 2011, the Chief of Staff’s Office will validate that unauthenticated 

documentation deficiencies have reduced to 20% or lower. 

Recommendation 3. We recommended that a comprehensive risk assessment be 

conducted to address examination tables and sharps containers throughout the facility 

and that identified deficiencies be corrected. 

Concur 

Target date for completion: February 28, 2011 

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CAP Review of the VA North Texas Health Care System, Dallas, TX 

VANTHCS completed an extensive risk analysis identifying examination tables requiring 

replacement and sharps containers necessitating relocation. The Chief, Engineering 

Service will validate 100% replacement of identified examination tables. The Bonham 

Quality Manager Specialist will validate 100% relocation of identified sharps containers. 

Recommendation 4. We recommended that staff document advance directive 

notification and document advance care planning using approved progress note titles. 

Concur 

Target date for completion: April 29, 2011 

Computerized Patient Record System (CPRS) documentation tools were updated to 

reflect VHA Handbook 1004.02 requirements. The Director of Corporate Quality 

Management and Customer Service will conduct audits of 30 patients, monthly for four 

months, to confirm that 95% of advanced care planning notification and documentation 

has been completed. 

Recommendation 5. We recommended that infection strategies education be provided 

to patients infected or colonized with MDRO and their families and be documented. 

Concur 

Target date for completion: April 29, 2011 

CPRS documentation tools were revised to record MDRO patient education. As of 

November 16, 2010, nursing staff received education regarding MDRO documentation 

requirements. The Director of Corporate Quality Management and Customer Service 

will conduct audits of 30 isolation patients, monthly for four months, to confirm that 95% 

of MDRO patient education is documented. 

Recommendation 6. We recommended that normal results be communicated to 

patients within the specified timeframe. 

Concur 

Target date for completion: August 31, 2011 

VANTHCS addressed this recommendation with a systems redesign approach. The 

redesign will encompass these improvements: 

 Formulate healthcare system policy to meet Directive 2009-019 

 Develop laboratory results communication tools 

 Refine methods and resources needed to implement redesigned processes 

 Implement redesigned processes and communications tools 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

	 From June 1st through August 31, 2011, the Director of Corporate Quality 

Management and Customer Service will conduct monthly audits of 40 patients 

with normal test results to validate 90% compliance with facility’s guidelines 

addressing communication of normal test results. 

VA OIG Office of Healthcare Inspections 20 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact	 Paula Chapman, CTRS 

Chicago Office of Healthcare Inspections 

Contributors	 Jennifer Reed, RN-BC, CAP Review Team Leader 

Lisa Barnes, MSW, CBOC Review Team Leader 

Shirley Carlile, BA 

Jody Marquez, BSN, RN 

Wilma Reyes, MD 

Kathleen Shimoda, RN 

Roberta Thompson, MSW 

Judy Brown, Program Support Assistant 

Rachel Malone, Special Agent, Office of Investigations 

Bryan Sewell, Special Agent, Office of Investigations 

Report Produced under the direction of Verena Briley-Hudson, MN, RN 

Preparation Director, Chicago Office of Healthcare Inspections 

VA OIG Office of Healthcare Inspections 21 
CAP Review of the VA North Texas Health Care System, Dallas, TX 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Heart of Texas Health Care Network (10N17) 

Interim Director, VA North Texas Health Care System (549/00) 

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: Tom Coburn, John Cornyn, Kay Bailey Hutchison, James M. Inhofe 

U.S. House of Representatives: Joe Barton, Dan Boren, Michael Burgess, Bill Flores, 

Louie Gohmert, Kay Granger, Ralph M. Hall, Jeb Hensarling, Eddie Bernice Johnson, 

Sam Johnson, Kenny Marchant, Randy Neugebauer, Pete Sessions, Mac Thornberry 

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

VA OIG Office of Healthcare Inspections 22