Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 08-03089-116

Combined Assessment Program 

Review of the 

Atlanta VA Medical Center 

Decatur, Georgia 

April 27, 2009

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 fraud and integrity awareness training 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 

Call the OIG Hotline – (800) 488-8244
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

Table of Contents 

Page 

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

Introduction ................................................................................................................ 1

Profile...................................................................................................................... 1

Objectives and Scope ............................................................................................. 2

Organizational Strengths........................................................................................... 3

Results ........................................................................................................................ 4

Review Activities With Recommendations .............................................................. 4

Quality Management ......................................................................................... 4

Suicide Prevention Program.............................................................................. 6

Contracted/Agency Registered Nurses ............................................................. 8

Coordination of Care ......................................................................................... 8

Medication Management ................................................................................... 9

Emergency/Urgent Care Operations ................................................................. 10

Review Activities Without Recommendations ......................................................... 11

Environment of Care.......................................................................................... 11

Survey of Healthcare Experiences of Patients .................................................. 12

Appendixes

A. VISN Director Comments .................................................................................. 15

B. Medical Center Director Comments................................................................... 16

C. OIG Contact and Staff Acknowledgments ......................................................... 23

D. Report Distribution............................................................................................. 24

VA Office of Inspector General 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

Executive Summary 

Introduction During the week of February 2–6, 2009, the OIG conducted 

a Combined Assessment Program (CAP) review of the 

Atlanta VA Medical Center (the medical center), Decatur, 

GA. The purpose of the review was to evaluate selected 

operations, focusing on patient care administration and 

quality management (QM). During the review, we also 

provided fraud and integrity awareness training to 

382 medical center employees. The medical center is part of 

Veterans Integrated Service Network (VISN) 7. 

Results of the 

Review 

The CAP review covered eight operational activities. We 

identified the following organizational strengths and reported 

accomplishments: 

• Women’s Health Initiative. 

• Emergency Department (ED) Annex. 

• Community Living Center (CLC) Remembrance 

Celebration. 

We made recommendations in six of the activities reviewed. 

For these activities, the medical center needed to: 

• Complete all peer reviews within the required timeframe. 

• Include documentation of peer review follow-up actions in 

committee minutes. 

• Consistently report peer review data to the Executive 

Committee of the Medical Staff (ECMS). 

• Conduct and document institutional and clinical disclosures 

in accordance with Veterans Health Administration (VHA) 

and local policy. 

• Collect relevant practitioner-specific data for use in 

privileging decisions. 

• Complete safety plans for all patients at high risk for 

suicide and monitor the documentation of those plans. 

• Consistently verify and document licensure of all registered 

nurses (RNs). 

• Consistently complete intra-facility transfer documentation, 

as required by local policy. 

• Consistently complete discharge documentation, as 

required by local policy. 

VA Office of Inspector General i
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

• Ensure that nurses consistently document the 

effectiveness of all pain medications within the required 

timeframe of the local policy. 

• Ensure that ED staff complete inter-facility transfer 

documentation, as required by VHA and local policy. 

The medical center complied with selected standards in the 

following two activities: 

• Environment of Care (EOC). 

• Survey of Healthcare Experiences of Patients (SHEP). 

This report was prepared under the direction of 

Dorothy Duncan, Associate Director, and Jennifer Kubiak, 

Healthcare Inspector, Kansas City Office of Healthcare 

Inspections. 

Comments The VISN and Medical Center Directors agreed with the CAP 

review findings and recommendations and provided 

acceptable improvement plans. (See Appendixes A and B, 

pages 15–22, for the full text of the Directors’ comments.) 

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 Office of Inspector General ii
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

VA Office of Inspector General 1 

Introduction 

Profile Organization. The medical center is a tertiary care facility 

located in Decatur, GA, that provides a broad range of 

inpatient and outpatient health care services. Outpatient 

care is also provided at five community based outpatient 

clinics (CBOCs) in East Point, Smyrna, Oakwood, 

Lawrenceville, and Stockbridge, GA, and at two outreach 

clinics in Decatur and Rome, GA. The medical center is 

part of VISN 7 and serves a veteran population of about 

451,000 throughout 48 counties in Georgia. 

Programs. The medical center provides a full range of 

inpatient and outpatient care, including primary, specialty, 

acute, and extended care services. Currently, the medical 

center has 153 operating hospital beds and 100 operating 

CLC beds.1

Affiliations and Research. The medical center is affiliated 

with Emory University’s School of Medicine and provides 

training for 125 medical residents in 33 training programs. 

The medical center also has active affiliation agreements 

with 34 other schools to provide training in various other 

health care disciplines. In fiscal year (FY) 2008, the 

medical center research program had 503 projects and a 

budget of $32.3 million. Important areas of research 

included infectious diseases, traumatic brain injury, low 

vision, oncology, and pulmonary diseases. 

Resources. In FY 2008, medical care expenditures totaled 

$386.4 million. The FY 2009 medical care budget is 

$410.6 million. FY 2008 staffing was 2,260 full-time 

employee equivalents (FTE), including 220 physician and 

559 nursing FTE. 

Workload. In FY 2008, the medical center treated 

67,321 unique patients and provided 50,228 inpatient days 

in the hospital and 30,860 inpatient days in the CLC. The 

inpatient care workload totaled 6,080 discharges, and the 

average daily censuses for the hospital and the CLC were 

137 and 84, respectively. Outpatient workload totaled 

681,629 visits. 

 

1

 A CLC (formerly called a nursing home care unit) provides compassionate, person-centered care in a safe and 

homelike environment to eligible veterans who require a nursing home level of care. 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

Objectives and 

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 fraud and integrity awareness training 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 work areas; 

interviewed managers and employees; and reviewed clinical 

and administrative records. The review covered the 

following eight activities: 

• Contracted/Agency RNs.

• Coordination of Care.

• Emergency/Urgent Care (E/UC) Operations.

• EOC.

• Medication Management.

• QM.

• SHEP. 

• Suicide Prevention Program. 

The review covered medical center operations for FY 2008 

and FY 2009 through February 5, 2009, and was done in 

accordance with OIG standard operating procedures for 

CAP reviews. We also followed up on select 

recommendations from our prior CAP review of the medical 

center (Combined Assessment Program Review of the 

Atlanta VA Medical Center, Atlanta, Georgia, Report 

No. 06-01571-231, September 29, 2006). The medical 

VA Office of Inspector General 2 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

center had corrected all findings related to health care from 

the prior CAP review. 

During this review, we also presented fraud and integrity 

awareness briefings for 382 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. Activities in the “Review Activities 

Without Recommendations” section have no reportable 

findings.

Organizational Strengths 

Women’s Health 

Initiative

In an effort to improve medication safety, a quality 

improvement team identified the need to consistently screen 

age appropriate women veterans for pregnancy and 

breastfeeding. The screen is now part of the template for 

documentation of medication reconciliation and patient 

assessment. If the screen is positive, a consult is sent to 

the women’s wellness program, and a warning flag is 

generated in the computerized medical record system. 

Women’s wellness staff review the flags monthly and make 

any appropriate changes.

Emergency 

Department Annex 

The medical center created a separate area for mental 

health (MH) patients who require emergency treatment. 

The annex has its own entrance and is staffed by MH 

providers 24 hours per day, 7 days per week. As a result, 

the medical emergency room is less crowded. Also, MH 

patients are treated in a more therapeutic environment and 

are ensured immediate access to practitioners who are 

aware of their unique needs. 

Community Living 

Center 

Remembrance 

Celebration 

This dignified celebration was designed to pay respect to 

and honor veterans after their death. CLC nursing staff 

drape the veteran’s body with the American flag, and “taps” 

is played. Family members, significant others, and CLC 

residents are invited to attend the celebration. After the flag 

is folded, it is sent to the funeral home and presented to the 

family on the day of the funeral. 

VA Office of Inspector General 3 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

VA Office of Inspector General 4 

Results 

Review Activities With Recommendations 

Quality 

Management 

The purpose of this review was to evaluate whether the 

medical center’s QM program provided comprehensive 

oversight of the quality of care and whether senior 

managers actively supported the program’s activities. We 

interviewed the medical center’s senior management team 

and QM personnel. We evaluated plans, policies, and other 

relevant documents. 

The QM program was generally effective in providing 

oversight of the medical center’s quality of care, and senior 

managers supported the program. Appropriate review 

structures were in place for 11 of the 14 program activities 

reviewed. We identified three areas that needed 

improvement. 

Peer Review. Peer reviews were not completed within the 

120-day timeframe, as required by VHA and local policy.2

During FY 2008, timely completion of peer reviews ranged 

from 56 to 80 percent. Medical center staff developed 

action plans, and results from the 1st quarter of FY 2009 

showed improvement. However, we will monitor reports 

from future quarters to ensure continued improvement. 

Follow-up on recommendations made by the Peer Review 

Committee (PRC) was not documented in subsequent 

committee minutes. PRC minutes identified several 

recommendations for action throughout the year, but 

documentation of the status of these recommendations was 

not present. During our review, QM staff were able to 

provide us with current status and proof of actions taken. 

However, this information was not readily available to 

committee members. 

Additionally, peer review data were not consistently 

reported to the ECMS for communication of aggregate peer 

review data to medical staff leadership. According to local 

policy, the PRC is responsible for providing quarterly reports 

to the ECMS for identification of trends in care. We 

reviewed 4 quarters of ECMS minutes and were unable to 

find peer review reports for the 3rd quarter of FY 2008. We 

were told that because providers were not completing peer 

 

2

 VHA Directive 2008-004, Peer Review for Quality Management, January 28, 2008. 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

VA Office of Inspector General 5 

reviews within 120 days, there had been delays in compiling 

data for the ECMS. As a result, 3rd quarter data was missed 

and never reported. 

Adverse Event Disclosure. The medical center did not 

consistently document disclosure of adverse events, as 

required by VHA and local policy.3 Local policy requires 

that disclosure be a routine part of the response to a 

harmful or potentially harmful event and be documented in 

the patient’s medical record using a VHA-mandated 

template. 

We reviewed five medical records containing events that 

required institutional disclosure. In one of the five records, 

we found no documentation of disclosure. The medical 

center did not maintain a log of clinical disclosures. To 

obtain our clinical disclosure sample, we randomly selected 

two records from among PRC cases that should have been 

clinically disclosed based on the PRC’s conclusions. Staff 

agreed that these cases should have been disclosed but 

were unable to provide the required medical record 

documentation. 

Credentialing and Privileging. Service chiefs did not 

consistently collect and utilize appropriate quality data to 

evaluate physician performance for granting and renewing 

clinical privileges, as required by VHA.4 We reviewed 

13 physician profiles and found that 9 (69 percent) did not 

have relevant practitioner-specific data to support renewal 

of clinical privileges. Of the six services represented in our 

sample, two provided meaningful data while the other four 

only collected data related to workload, which gave little 

insight into the quality of care. Also, local policy requires 

that an ongoing, professional practice evaluation that 

includes specific measures be used to continuously 

evaluate a practitioner’s professional performance. Not all 

services collected specific measures. 

Recommendation 1 We recommended that the VISN Director ensure that the 

Medical Center Director requires that all peer reviews are 

completed within the required timeframe. 

 3

 VHA Directive 2008-002, Disclosure of Adverse Events to Patients, January 18, 2008. 4

 VHA Handbook 1100.19, Credentialing and Privileging, October 2, 2007. 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

VA Office of Inspector General 6 

Recommendation 2 We recommended that the VISN Director ensure that the 

Medical Center Director requires that PRC minutes include 

documentation of follow-up actions. 

Recommendation 3 We recommended that the VISN Director ensure that the 

Medical Center Director requires consistent reporting of 

peer review data to the ECMS. 

Recommendation 4 We recommended that the VISN Director ensure that the 

Medical Center Director requires that all institutional and 

clinical disclosures are conducted and documented in 

accordance with VHA and local policy. 

Recommendation 5 We recommended that the VISN Director ensure that the 

Medical Center Director requires that all clinical services 

collect relevant practitioner-specific data for use in 

privileging decisions. 

The VISN and Medical Center Directors concurred with our 

findings and recommendations. The process for tracking 

peer review completion has been revised. The Risk 

Manager is now responsible for ensuring that PRC actions 

are competed and recorded in committee minutes. 

Quarterly peer review reports have been added to the 

standing agenda for the ECMS. The Risk Manager will 

ensure that all events requiring institutional disclosure are 

disclosed and documented. QM analysts have 

implemented a clinical disclosure database and will ensure 

that events are disclosed and documented. Service line 

managers collect data and complete competency 

assessment forms. A spreadsheet detailing data used in 

the provider review process has been developed for the 

Professional Standards Board. We find these action plans 

appropriate and will follow up on reported implementation 

actions to ensure completion. 

Suicide Prevention 

Program 

The purpose of this review was to determine whether the 

medical center had implemented a suicide prevention 

program that was in compliance with VHA regulations. We 

assessed whether senior managers had appointed Suicide 

Prevention Coordinators (SPCs) at the medical center and 

at any very large CBOCs, and we evaluated whether SPCs 

fulfilled all required functions.5 Also, we verified whether 

 

5

 Very large CBOCs are defined as clinics with more than 10,000 unique patients enrolled. None of the medical 

center’s CBOCs met this criterion. 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

VA Office of Inspector General 7 

medical records of patients determined to be at high risk for 

suicide contained Category II Patient Record Flags (PRFs), 

documented safety plans that addressed suicidality, and 

documented collaboration between MH providers and 

SPCs.6

We interviewed the medical center SPC and the QM liaison 

for MH. We reviewed pertinent policies and the medical 

records of seven medical center patients and three CBOC 

patients determined to be at risk for suicide. The medical 

center SPC and two associate SPCs follow patients at the 

CBOCs. The SPC had entered Category II PRFs in all 

10 medical records, and there was documented 

collaboration between the SPC and MH providers. We 

found that the suicide prevention program was generally 

effective; however, we identified one area that needed 

improvement. 

Safety Plan Documentation. VHA regulations require that 

all medical records of patients at high risk for suicide 

contain a documented safety plan.7 The SPC, in 

coordination with other MH providers, had developed a 

safety plan template for the electronic medical record that 

included fields for meaningful, individualized information. 

However, only 3 (30 percent) of the 10 records that we 

reviewed included the required template. MH providers 

needed to complete the required safety plans in a timely 

manner for all patients at high risk for suicide. 

Recommendation 6 We recommended that the VISN Director ensure that the 

Medical Center Director requires that safety plans for all 

patients at high risk for suicide be completed and that 

documentation of those plans be monitored. 

The VISN and Medical Center Directors concurred with our 

findings and recommendation. The SPC will now review all 

patients added to the high-risk list to ensure that they have 

the templated safety plan completed within 7 days. The 

SPC will also ensure that plans are updated prior to 

discharge. We find this action plan appropriate and will 

follow up on reported implementation actions to ensure 

completion. 

 6

 A Category II PRF is an alert mechanism that is displayed prominently in medical records. 7

 VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, 

September 11, 2008. 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

Contracted/Agency 

Registered Nurses 

The purpose of this review was to evaluate whether RNs 

working in VHA facilities through contracts or temporary 

agencies met the same entry requirements as RNs hired as 

part of VHA facility staff. We reviewed documents for 

several required components, including licensure, training, 

and competencies. Also, we reviewed 10 files of 

contracted/agency personnel who worked at the medical 

center within the past year and identified one area that 

needed improvement. 

Licensure. The medical center did not utilize the same 

process for verification of licensure for contracted RNs that 

they used for full-time staff RNs. Full-time staff RNs provide 

their nursing licenses to Human Resources (HR) for 

verification, and HR staff document the dates of verification 

and expiration. Nursing management verifies contracted 

RNs’ licensure via internet nursing board websites. 

However, 5 (50 percent) of the 10 contracted RNs’ files did 

not have documentation of current licensure. During our 

inspection, nursing verified that all contracted RNs had 

current licensure. 

Recommendation 7 We recommended that the VISN Director ensure that the 

Medical Center Director requires that medical center staff 

consistently verify and document licensure of all RNs. 

The VISN and Medical Center Directors concurred with our 

findings and recommendation. Documentation of license 

verification has been added to the contract RN tracking 

spreadsheet. The process for contract RN licensure 

verification is now consistent with the process used for staff 

RNs. We find this action plan appropriate and will follow up 

on reported implementation actions to ensure completion. 

Coordination of 

Care 

The purpose of this review was to evaluate whether 

inpatient consultations, transfers, and discharges were 

coordinated appropriately and met VHA requirements. 

Coordinated consultations, transfers, and discharges are 

essential to an integrated, ongoing care process resulting in 

optimal patient outcomes. 

We reviewed the medical records of 24 inpatients that had 

consults ordered and performed internally. In general, we 

found that inpatients received consultative services within 

acceptable timeframes. We identified two areas that 

needed improvement. 

VA Office of Inspector General 8 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

Transfer Documentation. We found that 7 (29 percent) of 

24 intra-facility transfers did not have the required medical 

record documentation specified by local policy. None of the 

seven included the required nursing documentation, and 

one of the seven did not include the required physician 

documentation. 

Discharge Documentation. We found that 11 (46 percent) 

of 24 medical records did not have patient discharge 

instructions that were consistent with the patient discharge 

summary. Additionally, nurses had not documented the 

locally required discharge education in 2 (8 percent) of the 

24 records. 

Recommendation 8 We recommended that the VISN Director ensure that the 

Medical Center Director requires staff to consistently 

complete intra-facility transfer documentation, as required 

by local policy. 

Recommendation 9 We recommended that the VISN Director ensure that the 

Medical Center Director requires staff to consistently 

complete discharge documentation, as required by local 

policy. 

The VISN and Medical Center Directors concurred with our 

findings and recommendations. Processes have been 

implemented to monitor compliance with documentation of 

inter-facility transfers and discharges. We find these action 

plans appropriate and will follow up on reported 

implementation actions to ensure completion. 

Medication 

Management 

The purpose of this review was to evaluate whether VHA 

facilities had adequate medication management practices. 

A safe medication management system includes medication 

ordering, administering, and monitoring. 

We reviewed selected medication management processes 

in the inpatient medical and surgical units, the intensive 

care units (ICUs), and the CLC. We found adequate 

management of medications brought into the facility by 

patients or their families. Nurses appropriately scanned 

patient armbands and used personal identifiers prior to 

medication administration. We identified one area that 

needed improvement. 

Documentation of Pain Medication Effectiveness. Nurses 

did not consistently document the effectiveness of pain 

VA Office of Inspector General 9 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

medications in accordance with local policy requirements. 

We reviewed the Bar Code Medication Administration 

records of 46 patients who were hospitalized in selected 

units at the time of our visit. For each patient, we 

reviewed documentation for several doses of pain 

medication. Nurses documented pain medication 

effectiveness within the required timeframe of 4 hours for 

only 164 (58 percent) of the 284 doses of pain medication. 

Recommendation 10 We recommended that the VISN Director ensure that the 

Medical Center Director requires that nurses consistently 

document the effectiveness of all pain medications within 

the required timeframe of the local policy. 

The VISN and Medical Center Directors concurred with our 

findings and recommendation. Nursing Service has 

implemented a process to ensure timely documentation of 

pain medication effectiveness. Nurse managers are 

monitoring for compliance. We find these action plans 

appropriate and will follow up on reported implementation 

actions to ensure completion. 

Emergency/Urgent 

Care Operations 

The purpose of this review was to evaluate whether VHA 

facility E/UC operations complied with VHA guidelines 

related to hours of operation, clinical capability (including 

management of patients with acute mental health conditions 

and patients transferred to other facilities), staffing 

adequacy, and staff competency. In addition, we inspected 

the medical center’s ED for cleanliness and safety. 

The ED is located within the main hospital building and is 

open 24 hours per day, 7 days per week. The emergency 

services provided are within the medical center’s patient 

care capabilities. 

We reviewed medical records of patients who presented in 

the ED with acute mental health conditions, and in all cases, 

we found that staff managed the patients’ care 

appropriately. We reviewed the ED nurse staffing plan and 

time schedules and determined that managers had 

consistently followed their established staffing guidelines for 

allocating nursing resources. We also found that managers 

had appropriately documented nurse competencies. 

VA Office of Inspector General 10 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

VA Office of Inspector General 11 

We determined that the ED complied with VHA operational 

standards, including staffing guidelines, cleanliness, and 

competency. However, one area needed improvement. 

Inter-Facility Transfers. ED staff did not document specific 

inter-facility transfer data, as required by VHA and local 

policy.8 The movement of acutely ill patients from one 

institution to another exposes them to risks. Failing to 

transfer patients may be equally risky. VHA has the 

responsibility to ensure that transfers into and out of its 

medical facilities are carried out appropriately to assure 

maximum patient safety and to comply with the intent of the 

Emergency Medical Treatment and Labor Act. 

None of the medical records we reviewed contained all the 

required documentation elements. During onsite interviews, 

ED staff identified their local inter-facility transfer policy, and 

they provided paper forms that contained all required 

documentation elements. However, staff did not 

consistently complete the forms. We were told that there 

are plans to develop an electronic inter-facility transfer 

template. 

Recommendation 11 We recommended that the VISN Director ensure that the 

Medical Center Director requires ED staff to complete 

inter-facility transfer documentation, as required by VHA 

and local policy. 

The VISN and Medical Center Directors concurred with our 

findings and recommendation. Staff have implemented 

VHA’s electronic transfer template, and compliance is being 

monitored. We find this action plan appropriate and will 

follow up on reported implementation actions to ensure 

completion. 

Review Activities Without Recommendations 

Environment of 

Care 

The purpose of this review was to determine whether the 

medical center complied with selected infection control (IC) 

standards and maintained a clean and safe health care 

environment. Medical centers are required to establish a 

comprehensive EOC program that fully meets VA National 

Center for Patient Safety, Occupational Safety and Health 

Administration, and Joint Commission standards. 

 

8

 VHA Directive 2007-015, Inter-Facility Transfer Policy, May 7, 2007. 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

We evaluated the IC program to determine compliance with 

VHA directives that require management to collect and 

analyze data to improve performance. IC staff appropriately 

monitored, trended, analyzed, and reported infection data to 

clinicians for implementation of quality improvements to 

reduce infection risks for patients and staff. 

We conducted onsite inspections of ambulatory care areas, 

all medical and surgical inpatient units, the MH unit, both 

CLC units, the telemetry unit, the dialysis unit, and all ICUs. 

We also inspected the laboratory. We found that the 

medical center maintained a generally clean and safe 

environment. Nurse managers on the inpatient units 

expressed high satisfaction with the responsiveness of the 

housekeeping staff. Safety guidelines were met, and risk 

assessments complied with VHA standards. We made no 

recommendations. 

Survey of 

Healthcare 

Experiences of 

Patients 

The purpose of this review was to assess the extent that 

VHA medical centers use quarterly survey results of 

patients’ health care experiences with the VHA system to 

improve patient care, treatment, and services. The 

Performance Analysis Center for Excellence of the Office of 

Quality and Performance within VHA is the analytical, 

methodological, and reporting staff for SHEP. VHA set 

performance measure goals for patients reporting overall 

satisfaction of “very good” or “excellent” at 76 percent for 

inpatients and 77 percent for outpatients. Medical centers 

are expected to address areas that fall below target scores. 

We reviewed the inpatient and outpatient survey results for 

each quarter, beginning with the 4th quarter of FY 2006 and 

ending with the 3rd quarter of FY 2008. Figures 1 and 2 on 

the next page show the medical center’s SHEP 

performance measure results for inpatients and outpatients, 

respectively. 

VA Office of Inspector General 12 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

60

65

70

75

80

85

90

95

100

Qtr 4 (FY 06) Qtr 1 (FY 07) Qtr 2 (FY 07) Qtr 3 (FY 07) Qtr 4 (FY 07) Qtr 1 (FY 08) Qtr 2 (FY 08) Qtr 3 (FY 08)

Percent Reporting Overall Quality as Very Good or Excellent

Quarter Reported

Facility

VISN

National

ATLANTA VA MEDICAL CENTER

INPATIENT OVERALL QUALITY

BY QUARTER

Meets 

Target

Figure 1:

60

65

70

75

80

85

90

95

100

Qtr 4 (FY 06) Qtr 1 (FY 07) Qtr 2 (FY 07) Qtr 3 (FY 07) Qtr 4 (FY 07) Qtr 1 (FY 08) Qtr 2 (FY 08) Qrt 3 (FY 08)

Percent Reporting Overall Quality as Very Good or Excellent

Quarter Reported

Facility

VISN

National

ATLANTA VA MEDICAL CENTER

OUTPATIENT OVERALL QUALITY

BY QUARTER

Figure 2:

Meets 

Target

The medical center scored above the 76 percent target in 

1 of the last 8 quarters of available data for inpatient overall 

VA Office of Inspector General 13 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

VA Office of Inspector General 14 

quality; it scored above the 77 percent target in 3 of the last 

8 quarters of available data for outpatient overall quality. 

The medical center’s Director shared SHEP data with staff, 

service chiefs, and patients. All data were analyzed, action 

plans were appropriate, and actions were taken. 

Improvements in both inpatient and outpatient scores are 

now evident; therefore, we made no recommendations. 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 15 

Department of 

Veterans Affairs Memorandum 

Date: March 24, 2009 

From: Director, VA Southeast Network (10N7) 

Subject: Combined Assessment Program Review of the Atlanta 

VA Medical Center, Decatur, Georgia 

To: Director, Kansas City Healthcare Inspections Division 

(54KC) 

Director, Management Review Service (10B5) 

I have reviewed and concur with the recommendations and responses 

from the Atlanta VA Medical Center. 

(original signed by:) 

Lawrence A. Biro 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

Appendix B 

Medical Center Director Comments 

VA Office of Inspector General 16 

Department of 

Veterans Affairs Memorandum 

Date: March 23, 2009 

From: Director, Atlanta VA Medical Center (508/00) 

Subject: Combined Assessment Program Review of the Atlanta 

VA Medical Center, Decatur, Georgia 

To: Director, VA Southeast Network (10N7) 

I concur with the findings/recommendations presented in the Atlanta VA 

Medical Center OIG CAP review. Actions taken as a result of these 

findings are attached. 

 (original signed by:) 

James A. Clark, MPA 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

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 VISN Director ensure 

that the Medical Center Director requires that all peer reviews are 

completed within the required timeframe. 

Concur 

In January 2009 the process for tracking peer review completion was 

revised to provide a chain of responsibility notification for peer reviews that 

is activated prior to the peer review due date to ensure timeliness of 

completion. Since October 2008, all peer reviews have been timely for 

both the 45-day initial review and the 120-day Peer Review Committee 

review timeframes (25 of 25 Peer Reviews meeting the 45 and 

120 thresholds). 

Target Date: Completed 1/20/09. Although the process was strengthened 

by adding the chain of responsibility notification on January 20, 2009, 

tracking has demonstrated 100% peer reviews completed timely since 

October 2008. Ongoing monitoring is in place. 

Recommendation 2. We recommended that the VISN Director ensure 

that the Medical Center Director requires that PRC minutes include 

documentation of follow-up actions. 

Concur 

A worksheet was developed within the Peer Review database to track 

Peer Review Committee recommendations and follow-up responsibility. 

Follow-up actions are forwarded to the responsible staff by the Risk 

Manager with a 30-day completion target. The Risk Manager ensures 

actions are completed and recorded in the next Peer Review Committee 

meeting minutes. The process redesign was implemented on 2/10/09. 

There has been one meeting of the Peer Review Committee since 

implementation, and all follow-up actions were documented in the 

committee minutes. Ongoing monitoring is in place. 

Target Date: Completed 2/10/09. 

VA Office of Inspector General 17 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

Recommendation 3. We recommended that the VISN Director ensure 

that the Medical Center Director requires consistent reporting of peer 

review data to the ECMS. 

Concur 

A reporting schedule has been established for Peer Review quarterly 

reporting to the Executive Committee of the Medical Staff (ECMS) that 

allows reporting of peer review once the peer reviews initiated in the 

quarter have been closed (i.e., reviewed by the Peer Review Committee). 

The reporting schedule was developed on 2/10/09 and provided to the 

ECMS Committee organizer as a standing agenda for the ECMS 

presentation May, August, November, and February. 

Target Date: Completed 2/10/09. 

Recommendation 4. We recommended that the VISN Director ensure 

that the Medical Center Director requires that all institutional and clinical 

disclosures are conducted and documented in accordance with VHA and 

local policy. 

Concur 

A process was implemented on 2/17/09 whereby the Risk Manager 

ensures that all reported incidents requiring an institutional disclosure, the 

disclosure occurs and is properly documented in the computerized 

medical record. The A Clinical Disclosure database was developed. The 

Quality Management Analysts began a process of notifying the clinical 

provider when review of incidents and or occurrences reveal the need for 

clinical disclosure. The QM Analyst will ensure the clinical disclosure 

occurs and is documented in the computerized record. Since 2/17/09, 

there have been three incidents requiring disclosure with all conducted 

and documented appropriately. 

Target Date: Completed 2/17/09. Ongoing monitoring is in place. 

Recommendation 5. We recommended that the VISN Director ensure 

that the Medical Center Director requires that all clinical services collect 

relevant practitioner-specific data for use in privileging decisions. 

Concur 

The Service Line Manager collects data and completes a competency 

assessment sheet for presentation to the Professional Standards Board. 

The raw data is not maintained in the Credentialing area. During the OIG 

review, raw data from one Service Line was available and found to be in 

compliance. At the time of the OIG review the Service Line Manager and 

Section Chief were not physically available to provide their raw data. The 

VA Office of Inspector General 18 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

raw data was located in a protected area because it contained patient 

information from chart reviews. Since the OIG review, the two individuals 

have given access to other key personnel in the service to ensure it will be 

available when requested. 

The Manager/Section Chief of each department determines on-going 

monitoring. Departments tailor competency assessment forms to meet 

department activities. For example, Endocrinology Section conducts chart 

reviews for total thyroid ultrasound reports done or supervised, addresses 

and documents appropriate aspects of ultrasound, thyroid biopsies done 

or supervised, addresses diabetes preventive are in comprehensive 

manner (lipids, HTN, eye exam, foot exam, glycemic control, ASA). The 

Section reviews resident supervision, complaints/dissatisfaction from 

patients, effective communication with physicians and other clinic staff, 

compliments from staff/patients, appropriately uses facility resources for 

patient care, delinquent medical records, signed charts within 24 hours, 

co-signed trainee notes within 24 hours, completed consults within 

24 hours. Triggers are assigned for each activity. Other areas reviewed 

are: compliance issues, CME hours, involvement in malpractice suits, 

adverse actions, voluntary/mandatory reduction of privileges, reports to 

the NPDB and FSMB, and completed perception surveys that were 

distributed to the supporting clinical staff that interact with the provider. 

In addition to on-going monitoring by the departments, the Professional 

Standards Board reviews documentation supplied by the provider 

indicating the number of procedures performed during the rating period 

and reviews the clinical activity report obtained from the primary practice 

location of the provider. This information is reviewed by the committee 

members and compared with the privilege request to determine if the 

provider has actively utilized the procedure during the review period. 

Tracers conducted during 2008 identified the activity of on-going 

monitoring with various departments. Departments reviewed were 

collecting data to support privilege request. Tracers of on-going 

monitoring are part of the Periodic Performance Review for Medical Staff 

activities and will continue throughout 2009-2010. 

Additional improvements include the development of a master 

spreadsheet detailing the raw data used in the review process of each 

provider for sharing with the Professional Standards Board. 

Target Date: April 23, 2009. 

Recommendation 6. We recommended that the VISN Director ensure 

that the Medical Center Director requires that safety plans for all patients 

at high risk for suicide be completed and that documentation of those 

plans be monitored. 

VA Office of Inspector General 19 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

Concur 

The Suicide Prevention Coordinator (SPC) was in the process of 

reviewing and ensuring that safety plans for high risk patients included all 

of the required elements outlined in the October Suicide Prevention 

training. Although many of the notes contained the required elements in 

the electronic progress notes or scanned document, the documentation 

was not in a uniform template. A new note title and template, with all the 

required elements, was fully implemented 2/28/09. By 2/28/09, all current 

high risk patients had been reviewed by the SPC with the new template 

initiated on any patient identified as not having a safety plan containing all 

of the required elements. A process was implemented on 2/28/09 for the 

SPC to review all patients newly added to the high risk list to ensure that 

they have the templated safety plan completed within 7 days. Additionally, 

all patients being discharged from the high risk protocol are reviewed by 

the SPC to ensure the safety plan is updated prior to discharge. Ongoing 

monitoring results reveal 100% compliance for all patients newly placed 

on the high risk list. The results of this monitor is presented monthly at the 

Service Line Clinical Operations Committee and quarterly to the SL 

Performance Improvement Council. 

Target Date: Completed 2/28/09. Ongoing monitoring is in place. 

Recommendation 7. We recommended that the VISN Director ensure 

that the Medical Center Director requires that staff consistently verify and 

document licensure of all RNs. 

Concur 

All nurses both contract and VA staff have initial verification of licensure 

via the Vet Pro system. All contract nurse license expirations are provided 

to the office of the Associate Nurse Executive, Staffing/Resources where 

the information is placed in a computerized contract nurse tracking 

spreadsheet. The tracking spreadsheet is reviewed at the beginning of 

each month to identify each license that is due to expire that month. The 

online verification is checked to identify if the license has been renewed. 

If not, the agency is notified and the nurse is not permitted to work until the 

license is verified as renewed. Once verified, a copy of the verification of 

the license renewal is placed in the contract nurse folder. The date of 

license verification, date of printing of the verification, name of the staff 

member completing the verification and license expiration date is entered 

on the tracking spreadsheet. The Nurse Credentialing Coordinator 

completes an on-line verification as well; consistent with the practice for 

verifying Atlanta VA Medical Center nursing staff. Ongoing review by the 

Associate Nurse Executive, Staffing/Resources indicates 100% 

compliance with this process. Currently six licenses have been identified 

through this process for renewal prior to 3/31/09. Four have been verified 

VA Office of Inspector General 20 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

as renewed and two are pending. The agency has been notified of these 

pending renewals as per the process described above. 

Target Date: Completed 2/6/09. 

Recommendation 8. We recommended that the VISN Director ensure 

that the Medical Center Director requires staff to consistently complete 

intra-facility transfer documentation, as required by local policy. 

Concur 

On 2/17/09, a process was implemented whereby the Charge Nurse on 

the night tour monitors all intra facility transfers received on the 

unit for documentation of concurrence and/or addendum to 

the transfer reassessment progress note. Monitoring demonstrates 

95% (95 of 100 intra facility transfers). Additionally, the Documentation 

Monitor was revised on 2/27/09 to include intra-facility transfer 

documentation and provide ongoing monitoring of compliance. 

Target Date: Completed 2/17/09. Ongoing monitoring in place as above. 

Recommendation 9. We recommended that the VISN Director ensure 

that the Medical Center Director requires staff to consistently complete 

discharge documentation, as required by local policy. 

Concur 

Service Chiefs will require attending physicians on the wards to oversight 

this process to ensure that discharge summaries are consistent with 

patient discharge instructions. The Chief of Staff has directed Service 

Chiefs to provide this guidance to inpatient attendings regarding their 

responsibility, and that compliance with this requirement be tracked as 

part of the evaluation process of ward attending staff. 

Target Date: May 31, 2009. 

Recommendation 10. We recommended that the VISN Director ensure 

that the Medical Center Director requires that nurses consistently 

document the effectiveness of all pain medications within the required 

timeframe of the local policy. 

Concur 

On 2/5/09, IT and the Clinical Applications Coordinator added a feature to 

BCMA which requires the nurse to document the PRN effectiveness pain 

score as well the reason for PRN administration. On 2/13/09, the Charge 

Nurse on all shifts began printing the PRN Effectiveness list every 3 hours, 

to ensure compliance with the policy for documentation of PRN 

VA Office of Inspector General 21 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

VA Office of Inspector General 22 

effectiveness. This report is also being used as a hand off tool when PRN 

effectiveness is pending during shift change. On 2/8/09, the BCMA 

Coordinator began providing daily BCMA PRN effectiveness reports to the 

Nurse Managers for follow-up. The BCMA PRN effectiveness report has 

demonstrated over 90% compliance (3209 of 3556 PRNs documented 

timely) with PRN effectiveness documentation within the timeframe of the 

policy since 3/1/09. Daily monitoring is continuing through March with 

weekly monitoring in April and then ongoing monthly BCMA PRN 

Effectiveness reports provided to the Nursing Leadership and Staff. 

Target Date: Completed 2/8/09. Ongoing monitoring plan as above. 

Recommendation 11. We recommended that the VISN Director ensure 

that the Medical Center Director requires ED staff to complete inter-facility 

transfer documentation, as required by VHA and local policy. 

Concur 

The VHA computerized transfer form template and I-MED consent was 

implemented on 2/17/09. Utilization Management is currently monitoring 

all transfers to ensure inter facility transfer documentation, as required by 

local policy and VHA, is completed. Since 2/17/09, monitoring 

demonstrates 95% compliance (54 of 57 transfers). 

Target Date: Completed 2/17/09. Ongoing monitoring is in place as above. 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

Appendix C 

VA Office of Inspector General 23 

OIG Contact and Staff Acknowledgments 

Contact Dorothy Duncan, Associate Director 

Kansas City Office of Healthcare Inspections 

(816) 997-6966 

Contributors Jennifer Kubiak, Team Leader 

Stephanie Hensel 

Reba Ransom 

James Seitz 

Carl Scott, Office of Investigations 
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia 

Appendix D 

VA Office of Inspector General 24 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Southeast Network (10N7) 

Director, Atlanta VA Medical Center (508/00) 

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: Saxby Chambliss, Johnny Isakson 

U.S. House of Representatives: John Barrow; Sanford D. Bishop, Jr.; Paul C. Broun; 

Nathan Deal; Phil Gingrey; Henry C. “Hank” Johnson, Jr.; Jack Kingston; John Lewis; 

John Linder; Jim Marshall; Tom Price; David Scott; Lynn A. Westmoreland 

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