Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 08-02561-75

Combined Assessment Program 

Review of the 

Edith Nourse Rogers Memorial 

Veterans Hospital 

Bedford, Massachusetts 

February 24, 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 Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

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 Program........................................................................... 4 

Medication Management ................................................................................... 5 

Coordination of Care ......................................................................................... 7 

Environment of Care.......................................................................................... 8 

Emergency/Urgent Care Operations ................................................................. 9 

Review Activities Without Recommendations ......................................................... 10

Pharmacy Operations........................................................................................ 10

Staffing .............................................................................................................. 11

Survey of Healthcare Experiences of Patients .................................................. 11

Appendixes

A. VISN Director Comments .................................................................................. 14

B. Hospital Director Comments.............................................................................. 15

C. OIG Contact and Staff Acknowledgments ......................................................... 21

D. Report Distribution............................................................................................. 22

VA Office of Inspector General 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

Executive Summary 

Introduction During the week of December 8–12, 2008, the OIG 

conducted a Combined Assessment Program (CAP) review 

of the Edith Nourse Rogers Memorial Veterans Hospital (the 

hospital), Bedford, MA. 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 for 63 hospital employees. The hospital is part of 

Veterans Integrated Service Network (VISN) 1. 

Results of the 

Review 

This CAP review covered eight operational activities. We 

also followed up on two review areas from the June 2005 

CAP review. We identified the following organizational 

strengths and reported accomplishments:

• Improved colonoscopy timeliness. 

• Transitional beds for homeless veterans. 

• Computerized police response system. 

We made recommendations in five of the activities reviewed. 

For these activities, hospital managers needed to: 

• Ensure that clinical data are consistently trended and 

analyzed. 

• Develop processes to ensure that action items identified 

through the root cause analysis (RCA) process are 

implemented and monitored and that the status of 

implementation is reported. 

• Ensure that clinical managers implement The Joint 

Commission’s (JC) national patient safety goal (NPSG) 

for anticoagulation therapy. 

• Ensure the documentation of pain medication 

effectiveness within the required timeframe. 

• Develop a standardized procedure for medication 

administration for patients in isolation. 

• Ensure that nurses document patient transfer notes in 

accordance with hospital policy. 

• Ensure that patient discharge orders are documented in 

the medical record prior to patients being discharged. 

VA Office of Inspector General i
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

• Ensure that medication refrigerator temperatures are 

monitored daily and that controlled substances (CS) 

stored in medication refrigerators are secured. 

• Ensure that suicide prevention information is available in 

all patient care areas. 

• Ensure that discharged urgent care (UC) clinic patients 

receive written instructions. 

The hospital complied with selected standards in the 

following three activities: 

• Pharmacy Operations. 

• Staffing. 

• Survey of Healthcare Experiences of Patients (SHEP). 

This report was prepared under the direction of 

Katherine Owens, Director, Bedford Office of Healthcare 

Inspections. 

Comments The VISN and Hospital Directors agreed with the CAP 

review findings and recommendations and provided 

acceptable improvement plans. (See Appendixes A and B, 

pages 14–20 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 Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

VA Office of Inspector General 1 

Introduction 

Profile Organization. The hospital is located in Bedford, MA, and 

provides long-term care and mental health (MH) services. It 

also provides primary care services at four community based 

outpatient clinics in Fitchburg, Gloucester, Haverhill, and 

Lynn, MA. The hospital is part of VISN 1 and serves a 

veteran population of more than 450,0001 in the East 

Market.2 

Programs. The hospital provides comprehensive health 

care through primary care, long-term care, residential care, 

and inpatient and outpatient MH services. 

Affiliations and Research. The hospital is affiliated with 

Boston University’s School of Medicine, the University of 

Massachusetts’ Medical School, and Harvard School of 

Dental Medicine. Forty-eight residents rotated through the 

hospital during the last academic year. The hospital also 

provides training in nursing and other health care 

professions, such as psychology, pharmacy, social work, 

and physical and occupational therapy. 

The hospital is a VA Health Services Research and 

Development Center of Excellence focused on health quality 

assessment, health outcomes measurement, and health 

economics. It has a research budget of more than 

$5 million, and the research program has approximately 

165 projects and 66 investigators. 

Resources. In fiscal year (FY) 2008, the hospital’s medical 

care budget totaled approximately $139 million. FY 2008 

staffing was 1,154 full-time employee equivalents (FTE), 

including 45 physician and 383 nursing FTE. 

Workload. In FY 2008, the hospital treated approximately 

17,500 unique patients and provided inpatient care to more 

than 1,700 patients. It had 117 operating hospital beds with 

an average daily census (ADC) of 89 and 304 operating 

community living center (CLC)3

 beds with an ADC of 241. 

Outpatient workload totaled over 175,000 visits. 

 

1

 The hospital is a referral center for the VA Boston Healthcare System in Massachusetts and the Providence VA 

Medical Center in Rhode Island, which accounts for the large number of veterans served. 

2

 Geographically, the East Market includes all Massachusetts counties east of Worchester and the entire state of 

Rhode Island. 

3

 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 Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

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: 

• Coordination of Care.

• Emergency/UC (E/UC) Operations.

• Environment of Care (EOC).

• Medication Management.

• Pharmacy Operations.

• QM Program.

• SHEP.

• Staffing.

The review covered hospital operations for FY 2008 and was 

done in accordance with OIG standard operating procedures 

for CAP reviews. We also followed up on recommendations 

from the prior CAP review of the hospital (Combined 

Assessment Program Review of the Edith Nourse Rogers 

Memorial Veterans Hospital, Bedford, Massachusetts, 

Report No.05-01508-114, March 27, 2006). In that report, 

we identified improvement opportunities in radiology 

VA Office of Inspector General 2 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

timeliness and EOC. During the follow-up review, we found 

sufficient evidence that managers had implemented 

appropriate actions to address the identified deficiencies, 

and we consider those issues closed. 

During this review, we provided fraud and integrity 

awareness training for 63 employees. The training 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 made 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 

Improved 

Colonoscopy 

Timeliness 

In August 2006, the hospital arranged to have colonoscopy 

procedures performed at a community hospital in an effort to 

ensure timely patient care. Currently, four community 

hospitals are utilized for this service. As a result, the time for 

a patient to have a colonoscopy performed improved from 

159 days in March 2007 to 19 days in November 2008. The 

hospital continues to monitor timeliness to ensure that 

improvement is sustained over time. 

Transitional Beds 

for Homeless 

Veterans 

In July 2007, the hospital developed a transitional bed 

program to ensure that homeless patients waiting for 

admission to the substance use disorder (SUD) treatment 

program had safe and supervised transitional housing. Prior 

to implementation of the program, patients who had no 

permanent housing either remained on the acute inpatient 

psychiatry unit, which was costly, or were discharged to 

homeless shelters until a hospital lodging bed became 

available. The hospital now temporarily houses the patients 

in community residential care beds. Since the inception of 

the program, the hospital has reported a cost avoidance of 

approximately $683,000 and a decrease in the number of 

patients lost to SUD treatment. 

Computerized 

Police Response 

System 

The hospital implemented a computerized police response 

system. The Lynx system is a computer desktop based 

system that uses the information technology network to 

transmit panic alarms to a central receiving location in the 

VA Office of Inspector General 3 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

VA Office of Inspector General 4 

Police Service Dispatch Center. The system is activated by 

a designated “hotkey” combination that identifies the exact 

location of the desktop from which the alarm was sent and 

triggers a police response. 

Results 

Review Activities With Recommendations 

Quality 

Management 

Program 

The purpose of this review was to evaluate whether the 

hospital had a comprehensive QM program designed to 

monitor patient care quality and whether senior managers 

actively supported the program’s activities. We evaluated 

policies, performance improvement (PI) data, and other 

relevant documents, and we interviewed appropriate senior 

managers and the QM Coordinator. 

The hospital’s QM program was generally effective, and 

senior managers supported the program through 

participation in and evaluation of PI initiatives and through 

allocation of resources to the program. However, we 

identified two areas that needed improvement. 

Data Analysis. The hospital collected appropriate data; 

however, a sample review of data and committee minutes 

showed that in-depth analysis of data was frequently lacking 

and that data were not consistently trended over time. 

Consequently, evidence regarding how managers used data 

to identify improvement opportunities was limited. 

Patient Safety. Veterans Health Administration (VHA) 

regulations4

 require that health care organizations ensure 

that action items identified through the RCA process are 

implemented and monitored for efficacy. We found that 

RCAs were generally thorough; however, it was difficult to 

track actions to closure and to determine how managers 

monitored the effectiveness of actions. The hospital needed 

to develop processes to ensure that responsible managers 

implement and monitor corrective actions and report the 

status of those actions until they are closed. 

Additionally, managers did not have a plan to implement the 

NPSG to reduce potential patient harm associated with 

anticoagulation therapy. Although hospital managers had 

designated responsibility for the development and 

 

4

 VHA Handbook 1050.01, VHA National Patient Safety Improvement Handbook, May 23, 2008. 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

implementation of the plan, at the time of our review, this had 

not been fully accomplished. 

Recommendation 1 We recommended that the VISN Director ensure that the 

Hospital Director requires that clinical data are consistently 

trended over time and analyzed to identify improvement 

opportunities. 

Recommendation 2 We recommended that the VISN Director ensure that the 

Hospital Director requires the development of effective 

processes to ensure that RCA action items are implemented 

and monitored and that the status of implementation is 

reported to an appropriate committee. 

Recommendation 3 We recommended that the VISN Director ensure that the 

Hospital Director requires that managers fully implement the 

NPSG for anticoagulation therapy. 

The VISN and Hospital Directors agreed with the findings 

and recommendations. They reported that training on 

concepts of data management, analysis, and trending will be 

provided to responsible staff and that senior managers are 

actively recruiting for a data analyst to support staff in the 

use of data management tools. Managers will be required to 

report RCA action item progress to the QM Board, which will 

review RCAs during monthly meetings. They also reported 

that clinical managers have developed a plan to ensure the 

implementation of the NPSG for anticoagulation therapy. 

The implementation plans are acceptable, and we will follow 

up on the planned actions until they are completed. 

Medication 

Management

The purpose of this review was to evaluate whether VHA 

health care facilities had adequate medication management 

processes to ensure safe ordering, dispensing, 

administering, and monitoring of medications. We reviewed 

medication management processes on inpatient and CLC 

units, and we interviewed nurse managers and other nursing 

staff. Additionally, we observed nurses administering 

medications, and we asked patients if nurses scanned their 

wristbands prior to administering their medications. 

We found adequate management of medications brought 

into the facility by patients or their families. Additionally, we 

found that the processes for reconciling CS discrepancies at 

the unit level were adequate. However, we identified two 

areas that needed improvement. 

VA Office of Inspector General 5 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

VA Office of Inspector General 6 

Pain Medication Effectiveness. VHA regulations5 require 

that clinicians monitor PRN6

 pain medications for 

effectiveness. Additionally, the hospital’s policy governing 

PRN pain medications requires that effectiveness 

assessments occur within 4 hours after administration. We 

reviewed 428 administered doses of PRN pain medications 

and found that effectiveness assessments were not 

documented within the required timeframe for 184 (43 

percent) of the doses. 

Medication Administration. The hospital’s policy governing 

medication administration requires nurses to scan patients’ 

wristbands before administering medications. Scanning 

wristbands correctly identifies patients and reduces 

medication errors. However, this can be challenging when 

patients require isolation because equipment taken into an 

isolation room can become contaminated during the 

scanning process. Neither the hospital’s medication 

administration policy nor infection control (IC) policies 

addressed procedures for the use of scanning equipment on 

isolated patients. We asked nurse managers and staff 

nurses about the procedures used, and we received varying 

answers. A standardized procedure would ensure that 

isolated patients have their wristbands scanned consistently 

and that equipment is properly protected to reduce the 

vulnerability of the spread of infections. 

Recommendation 4 We recommended that the VISN Director ensure that the 

Hospital Director requires the documentation of PRN pain 

medication effectiveness within the required timeframe. 

Recommendation 5 We recommended that the VISN Director ensure that the 

Hospital Director requires the development of a standardized 

medication administration procedure for patients in isolation. 

The VISN and Hospital Directors agreed with the findings 

and recommendations. They reported that nurse managers 

will monitor the status of documentation of PRN pain 

medication effectiveness weekly. They also reported that IC 

and clinical applications managers will develop procedures 

for administration of medications to patients in isolation and 

for the protection of BCMA equipment used to scan their 

wristbands. The implementation plans are acceptable, and 

 

5

 VHA Directive 2003-021, Pain Management, May 2, 2003. 6

 PRN is a Latin abbreviation [L pro re nata] meaning as needed or as the circumstances require. 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

VA Office of Inspector General 7 

we will follow up on the planned actions until they are 

completed. 

Coordination of 

Care

The purpose of this review was to evaluate whether VHA 

health care facilities had adequate processes to ensure 

coordination of care across the continuum of patient 

services. We reviewed three aspects of patient care: 

(a) consults, (b) intra-facility transfers, and (c) discharges. 

We found that providers managed patients’ consults 

appropriately. However, we identified two areas that needed 

improvement. 

Intra-Facility Transfers. The hospital’s policy governing 

patient transfers requires that nurses complete 

documentation that contains specific patient information prior 

to transfer. We reviewed medical record documentation for 

six patients transferred within the hospital and found 

deficiencies in five records. Two records had no transfer 

notes. The other three records did not contain all the 

elements required by the hospital’s policy. 

Patient Discharges. We reviewed medical record 

documentation for 12 patients discharged from inpatient 

units and found that 3 (25 percent) medical records showed 

that physicians wrote discharge orders 1 to 3 weeks after the 

date of discharge. Consequently, these three patients left 

the hospital without appropriate documentation that they had 

been discharged. VHA regulations require that patients be 

discharged only by the order of a physician.7 

Recommendation 6 We recommended that the VISN Director ensure that the 

Hospital Director requires that nurses document patient 

transfer notes in accordance with hospital policy. 

Recommendation 7 We recommended that the VISN Director ensure that the 

Hospital Director requires that patient discharge orders are 

documented in the medical record prior to patients being 

discharged. 

The VISN and Hospital Directors agreed with the findings 

and recommendations. They reported that managers will 

develop a patient transfer template to ensure documentation 

of all required information prior to patient transfer. Nurses 

will be trained on the use of the template. They further 

reported that senior clinical managers are developing 

 

7

 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

processes to ensure that discharge orders are documented 

in medical records prior to patient discharges and that the 

Medical Record Review Committee will monitor for 

compliance. The implementation plans are acceptable, and 

we will follow up on the planned actions until they are 

completed. 

Environment of 

Care

The purpose of this review was to determine whether the 

hospital complied with selected IC standards and maintained 

a clean, safe, and secure environment. VHA facilities are 

required to establish comprehensive EOC programs that fully 

meet VA, Occupational Safety and Health Administration, 

and JC accreditation standards. 

We inspected the following areas: (a) three psychiatry units, 

including the acute psychiatry unit; (b) the geriatric 

evaluation and management unit; (c) two CLC units; 

(d) three geriatric research and education clinical centers; 

(e) the dental clinic; and (f) the inpatient and outpatient 

pharmacies. The areas we inspected were clean and well 

maintained, and managers expressed satisfaction with the 

housekeeping staff assigned to their areas. Also, we 

evaluated the IC program’s management of data and 

processes in which the data were used to improve 

performance and found the program satisfactory. 

Additionally, we reviewed the acute psychiatry unit to 

determine if managers identified environmental hazards that 

potentially posed threats to patients and to ensure that staff 

received specialized training. The hospital provided 

documentation of risk assessment and abatement tracking of 

safety issues previously identified on the unit, and we found 

that suicide risk training was completed. However, we 

identified two areas that needed improvement. 

Safety. We found that temperature logs for two medication 

refrigerators were not monitored in accordance with the 

hospital’s policy governing refrigerator temperature 

monitoring. Documentation of daily temperature monitoring 

was lacking from the temperature logs for the medication 

refrigerator on one CLC unit and for one of the refrigerators 

in the inpatient pharmacy. Appropriate temperature controls 

ensure medication safety and maintenance of medication 

efficacy. Additionally, we found that a nursing unit 

medication refrigerator containing CS was unlocked and 

unattended. 

VA Office of Inspector General 8 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

VA Office of Inspector General 9 

Suicide Prevention Information. We found that suicide 

prevention materials were not posted in highly visible areas 

throughout the hospital, as required.8

 We noted that while 

some suicide prevention posters were in place, many 

provided just a website as contact information and lacked the 

suicide hotline phone number. Also, many high-traffic 

patient areas, such as pharmacy, primary care, optometry, 

and cardiology waiting rooms, lacked information. The 

dental clinic waiting room was the only location where 

pamphlets were available. 

Recommendation 8 We recommended that the VISN Director ensure that the 

Hospital Director requires that medication refrigerator 

temperatures are monitored daily and that CS stored in 

medication refrigerators are secured. 

Recommendation 9 We recommended that the VISN Director ensure that the 

Hospital Director requires that suicide prevention information 

is available in all patient care areas. 

The VISN and Hospital Directors agreed with the findings 

and recommendations. They reported that managers 

developed processes for daily monitoring of medication 

refrigerator temperatures and for security of CS stored in the 

medication refrigerators. They also reported that suicide 

prevention information is now available in all areas of the 

hospital. The implementation plans are acceptable, and we 

will follow up on the planned actions until they are 

completed. 

Emergency/Urgent 

Care Operations

The purposes of this review were to evaluate selected 

aspects of E/UC clinical services, consults, staffing, and staff 

competencies. We also evaluated whether the physical 

environment was clean and safe and whether managers 

maintained equipment appropriately. 

The hospital did not have an emergency department but 

operated a UC clinic during administrative hours. We 

interviewed clinic managers, staff members, and staff 

specifically involved in the transfer of clinic patients to other 

facilities. We reviewed policies and other pertinent 

documents, including equipment maintenance records. We 

also reviewed medical records of patients who were admitted 

 

8

 Deputy Under Secretary for Health for Operations and Management, memorandum to VISN and facility Directors, 

December 7, 2007. 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

VA Office of Inspector General 10 

to the hospital, discharged, or transferred to other medical 

facilities. 

Our review showed that consults and staffing were 

appropriate. We conducted an EOC tour and found that the 

area was clean and safe and that equipment was 

appropriately maintained. However, we identified one area 

that needed improvement. 

Written Discharge Instructions. JC accreditation standards 

require that written discharge instructions be provided to 

patients when they are discharged from an ambulatory care 

facility. We reviewed the medical records of 11 patients 

discharged from the UC clinic and found no documentation 

to support that the patients received written instructions.

Recommendation 10 We recommended that the VISN Director ensure that the 

Hospital Director requires that UC clinic patients receive 

written discharge instructions. 

The VISN and Hospital Directors agreed with the finding and 

recommendation. They reported that clinical managers have 

developed processes to ensure that UC clinic patients 

receive discharge instructions and that the Medical Record 

Review Committee will monitor for compliance. The 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

Review Activities Without Recommendations 

Pharmacy 

Operations 

The purposes of this review were to evaluate whether VHA 

health care facilities had adequate controls to ensure the 

security and proper management of CS and pharmacies’ 

internal physical environments and whether clinical 

managers had processes to monitor inpatient and outpatient 

medication use to avoid polypharmacy in vulnerable 

populations, such as the elderly and MH patients. 

Pharmacy Controls. We reviewed VHA regulations9

governing pharmacy and CS security, and we assessed 

whether the hospital’s policies and processes were 

consistent with VHA regulations. We reviewed the CS 

inspection program and inspected inpatient and outpatient 

 

9

 VHA Handbook 1108.1, Controlled Substances (Pharmacy Stock), October 4, 2004; VHA Handbook 1108.2, 

Inspection of Controlled Substances, August 29, 2003; VHA Handbook 1108.5, Outpatient Pharmacy, 

May 30, 2006; VHA Handbook 1108.6, Inpatient Pharmacy, June 27, 2006. 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

VA Office of Inspector General 11 

pharmacies for security, EOC, and IC issues. In addition, we 

interviewed the CS Coordinator, and appropriate Pharmacy 

Service managers. The hospital’s CS inspection program 

was organized and well managed. 

Polypharmacy. Pharmacological regimens involving multiple 

medications are often necessary to prevent and maintain 

disease states; however, excessive use of medications can 

result in adverse reactions and increased risks of 

complications. Polypharmacy is more complex than just the 

number of drugs that patients are prescribed. The clinical 

criteria to identify polypharmacy are the use of: 

(a) medications that have no apparent indication, 

(b) therapeutic equivalents to treat the same illness, 

(c) medications that interact with other prescribed drugs, 

(d) inappropriate medication dosages, and (e) medications to 

treat adverse drug reactions.10 Some literature suggests 

that elderly patients and MH patients are among the most 

vulnerable populations for polypharmacy.11

We interviewed pharmacy clinical managers to determine the 

hospital’s efforts to monitor and avoid inappropriate 

polypharmacy. Clinical pharmacists identified patients who 

were prescribed multiple medications, reviewed the patients’ 

medication regimens to avoid complications related to 

polypharmacy, and advised providers regarding potential 

polypharmacy complications when appropriate. We made 

no recommendations. 

Staffing The purpose of this review was to evaluate whether VHA 

health care facilities had developed comprehensive nurse 

staffing guidelines and whether the guidelines were followed. 

We reviewed nurse staffing documents for eight inpatient 

units, and we interviewed nurse managers. We found the 

staffing methodology to be appropriate. We made no 

recommendations. 

Survey of 

Healthcare 

Experiences of 

Patients 

The purpose of this review was to assess the extent that 

VHA health care facilities use quarterly or semi-annual 

SHEP results to improve patient care and services. The 

Performance Analysis Center for Excellence of the Office of 

Quality and Performance within VHA is the analytical, 

 

10 Yvette C. Terrie, BSPharm, RPh, “Understanding and Managing Polypharmacy in the Elderly,” Pharmacy Times, 

December 2004. 

11 Terrie, Pharmacy Times, December 2004; Vijayalakshmy Patrick, M.D., et al., “Best Practices: An Initiative to 

Curtail the Use of Antipsychotic Polypharmacy in a State Psychiatric Hospital,” Psychiatric Services, 57:21–23, 

January 2006. 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

VA Office of Inspector General 12 

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. 

We reviewed SHEP scores for quarter 4 of FY 2006 through 

quarter 3 of FY 2008. Figures 1 and 2 below and on the next 

page show the hospital’s patient satisfaction performance 

measure results for outpatients and inpatients, respectively. 

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)

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

Facility

VISN

National

EDITH NOURSE ROGERS MEMORIAL 

VETERANS HOSPITAL

OUTPATIENT OVERALL QUALITY

BY QUARTER

Figure 1:

Meets 

Target
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

40

45

50

55

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)

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

Facility

VISN

National

EDITH NOURSE ROGERS MEMORIAL 

VETERANS HOSPITAL

INPATIENT OVERALL QUALITY

BY QUARTER

Meets 

Target

Figure 2:

The outpatient scores were above target for all 8 quarters 

reviewed. The inpatient scores were above target for 5 of 

the 8 quarters reviewed. Managers analyzed SHEP data, 

developed improvement strategies, and monitored the 

results of the strategies. Survey results and improvement 

strategies were distributed throughout the organization. 

Therefore, we made no recommendations. 

VA Office of Inspector General 13 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 14 

Department of 

Veterans Affairs Memorandum 

Date: February 6, 2009 

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

Subject: Combined Assessment Program Review of the 

Edith Nourse Rogers Memorial Veterans Hospital, 

Bedford, Massachusetts

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

Director, Management Review Service (10B5) 

We concur with the recommendations and have actions listed below. 

Please contact VISN 1 Quality Management Officer (Allan Shirks, MD, 

781-687-4850) if anything further is needed. 

 (original signed by:) 

MICHAEL F. MAYO-SMITH, MD, MPH 

Network Director 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

Appendix B 

Hospital Director Comments 

VA Office of Inspector General 15 

Department of 

Veterans Affairs Memorandum 

Date: January 30, 2009 

From: Director, Edith Nourse Rogers Memorial Veterans Hospital 

(518/00) 

Subject: Combined Assessment Program Review of the Edith 

Nourse Rogers Memorial Veterans Hospital, Bedford, 

Massachusetts

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

Director, Management Review Service (10B5) 

1. We have reviewed the OIG draft report and appreciate the opportunity 

to provide comments. After careful review, we have concurred with all 

recommendations and have provided the following implementation plan. 

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

contact Mr. Michael Carey, Quality Manager, at (781) 687-3080. 

 (original signed by:) 

Tammy A. Follensbee 

 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

Comments to Office of Inspector General’s Report 

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

recommendations in the Office of Inspector General report: 

OIG Recommendations

Recommendation 1. We recommended that the VISN Director ensure 

that the Hospital Director requires that clinical data are consistently 

trended over time and analyzed to identify improvement opportunities. 

Concur 

Plan: A gap analysis will be conducted to determine current strengths 

and opportunities with respect to data management and analysis skills. 

Responsible staff for data management, analysis, and trending within their 

respective service and/or hospital committee will receive additional 

training on concepts for managing, analyzing, and trending data over time. 

In addition, designated staff will receive training on performance 

improvement opportunities and the role of data. Further, staff will be 

trained in the proper documentation of staff/committee minutes to properly 

reflect data analysis and follow-up actions. We plan to assign one person 

on each major hospital committee with the responsibility for ensuring data 

is properly analyzed and trended and actions are followed through to 

appropriate resolution. Currently, the center memo which defines format 

for staff/committee minutes is being revised to facilitate a standardized 

approach to documenting minutes. 

Bedford is actively recruiting a data analyst who will be instrumental in 

providing expertise and continued support for staff in the use of data 

management tools. The VISN education office has recently submitted a 

statement of work for a VISN wide educational program concerning 

“Collecting, Analyzing, Presenting Quality Data – Tips and Techniques for 

Getting Your Data Under Control,” and we have projected sending ten 

staff to that program. 

Target Date for Completion: June 1, 2009 

Recommendation 2. We recommended that the VISN Director ensure 

that the Hospital Director requires the development of effective processes 

to ensure that RCA action items are implemented and monitored and that 

the status of implementation is reported to an appropriate committee. 

Concur 

VA Office of Inspector General 16 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

Plan: The Patient Safety Manager maintains a log of all RCA approved 

recommendations and has coordinated with the Director’s Office to ensure 

status of implementation is reported directly to the Quality Management 

Board (QMB). A memo from the Hospital Director has been sent to all 

managers on January 29, stressing the importance of ensuring full 

implementation of all recommendations identified in each RCA. This 

memo highlighted the process change and informed managers they would 

be reporting updates of RCA recommendations to the QMB until 

completion. A reporting structure was created for monthly QMB meetings 

to include RCA reviews. 

Recommend this issue be closed. 

Recommendation 3. We recommended that the VISN Director ensure 

that the Hospital Director requires that managers fully implement the 

NPSG for anticoagulation therapy. 

Concur 

Plan: This was discussed at our QMB January 21, 2009, and a task 

group consisting of the Associate Director/Patient Nursing Service, 

ACOS/Geriatrics & Extended Care, Chief, Pharmacy, and Patient Safety 

Manager was appointed to assess current status and those actions 

necessary to bring us into full compliance. On January 27, they had their 

first meeting and reviewed all requirements of the NPSG. As a result, the 

following plan has been developed: 

• Expand the functions of existing Coumadin clinic to include, in 

addition to a pharmacist, a dietitian, Expanded Practice Nurse, and 

an administrative support person. Target Date – March 1, 2009

• Develop an anticoagulation management program to provide 

individualized care for all patients prescribed anticoagulation 

therapy. Target Date – March 1, 2009

• The anticoagulation team will review the records of all patients 

on Coumadin and will collaborate with the unit specific 

interdisciplinary team to assure proper coumadin dosing. Target 

Date – March 1, 2009 

• Update existing Coumadin clinic policy to reflect above plan. 

Target Date – March 1, 2009 

• Develop monitor to assess effectiveness of program. Target 

Date – March 1, 2009 

VA Office of Inspector General 17 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

• Monitoring for the first two months after implementation will be done 

by Quality Management and reported to the COS. Continued 

monitoring will be included into the functions of the P&T Committee.

Recommendation 4. We recommended that the VISN Director ensure 

that the Hospital Director requires the documentation of PRN pain 

medication effectiveness within the required timeframe. 

Concur 

Plan: A report to monitor PRN pain effectiveness will be run on a weekly 

basis and posted on a SharePoint site giving nurse managers and the 

nurse executive read only access. Nurse managers will monitor on a 

weekly basis, status of documenting the effectiveness of PRN medications 

and take corrective action as necessary. In addition, our local policy will 

be updated to require PRN effectiveness documentation within eight 

hours. This process will be monitored on a monthly basis with an 

expected rate of 90% completion and reported to the Clinical Services 

Performance Improvement Council (CSPIC) within 90 days of 

implementation. 

Target Date for Completion – March 30, 2009 

Recommendation 5. We recommended that the VISN Director ensure 

that the Hospital Director requires the development of a standardized 

medication administration procedure for patients in isolation. 

Concur 

Plan: The Infection Prevention and Control Practitioner will coordinate 

with the Clinical Applications Coordinator to develop a policy and 

procedure for scanning of the wrist bands on CLC and Behavioral Health 

veterans who are on contact or droplet precautions. In addition, the policy 

will ensure the BCMA cart is protected and when necessary properly 

disinfected so to prevent the spread of infection. 

Target Date for Completion – March 30, 2009 

Recommendation 6. We recommended that the VISN Director ensure 

that the Hospital Director requires that nurses document patient transfer 

notes in accordance with hospital policy. 

Concur 

Plan: The Clinical Applications Coordinator will develop a patient transfer 

template that contains specific patient information. This template will be 

placed in the shared template folder of CPRS for use when transferring 

patients. Target: February 28, 2009. Nurses will be educated on the 

VA Office of Inspector General 18 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

use of the template by April 30, 2009. A monitor will be developed and 

results reported to the Clinical Services PIC for appropriate action. 

Target Date for Completion – April 30, 2009 

Recommendation 7. We recommended that the VISN Director ensure 

that the Hospital Director requires that patient discharge orders are 

documented in the medical record prior to patients being discharged. 

Concur 

Plan: 

1. The Chief of Staff sent a memo to all physicians informing them of the 

need to document discharge orders in the medical record prior to the 

patient being discharged. Completion Date: January 29, 2009 

2. Hospital Memoranda #11.14, Electronic Orders and #122.03, 

Discharge Planning, will be modified to require the responsible 

physician to document an order for discharge at the time of discharge 

and that the discharge will not occur without the written order. 

Completion Date: March 30, 2009

3. Health Information Management Service (HIMS) will develop a monitor 

for the timeliness of discharge orders. The results of the monitor will be 

incorporated into the Medical Records Review Committee review 

schedule commencing January 30, 2009, thru July 31, 2009. After the 

six month time period, based on the data, the committee will review the 

needed frequency for further monitoring. 

Target Date for Completion: March 30, 2009 

Recommendation 8. We recommended that the VISN Director ensure 

that the Hospital Director requires that medication refrigerator 

temperatures are monitored daily and that CS stored in medication 

refrigerators are secured.

Concur 

Plan: The Associate Director/Patient Nursing Services assigned the 

monitoring of the refrigerator for temperatures and proper security to the 

night shift on each unit. Documentation of the monitoring is forwarded to 

the Nursing Administrative Coordinator who will forward this report to the 

Nurse Executive Group at morning report. In addition, nurse managers in 

out-patient settings and the Chief, Pharmacy Service, will send a daily 

E-Mail message to the Nursing Administrative Coordinator for inclusion in 

the reporting. This will be reviewed quarterly at the Clinical Services PIC. 

VA Office of Inspector General 19 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

VA Office of Inspector General 20 

Action complete: Recommend this issue be closed. 

Recommendation 9. We recommended that the VISN Director ensure 

that the Hospital Director requires that suicide prevention information is 

available in all patient care areas. 

Concur 

Plan: Our Suicide Prevention Coordinator conducted a facility 

assessment to determine all areas that needed suicide prevention 

materials. She collaborated with Environmental Management Service 

(EMS) to ensure that current suicide prevention materials were made 

available in all areas and that current suicide prevention posters were 

hung in identified areas. She is finalizing a process to ensure that printed 

materials are routinely replenished and updated as needed. 

Target Date for Completion – February 27th, 2009 

Recommendation 10. We recommended that the VISN Director ensure 

that the Hospital Director requires that UC clinic patients receive written 

discharge instructions. 

Concur 

Plan: Specialty & Acute Care Line Manager communicated the above 

findings to all ambulatory care staff in a staff meeting on 

December 23, 2008, and an ad-hoc group met on December 30, 2008, 

and discussed the current discharge instruction sheets that were being 

used. They suggested and implemented modifications to the discharge 

instruction sheets. During the Urgent Care staff meeting on 

January 20, 2009, the urgent care providers were re-educated to 

document that the discharge instructions sheets are being handed out. A 

process change was implemented to have all discharge instruction sheets, 

needing to be filled out, placed on the urgent care desk thus prompting the 

urgent care providers to complete them and document that they were 

given to the patient. All Urgent Care physicians are currently using the 

paper discharge instructions and documenting this process in CPRS. The 

Medical Record Review Committee will be tasked with incorporating this 

monitoring into their scheduled medical record review process. 

Target Date for completion – March 30, 2009 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

Appendix C 

VA Office of Inspector General 21 

OIG Contact and Staff Acknowledgments 

Contact Katherine Owens, MSN, Director 

Bedford Office of Healthcare Inspections 

(603) 222-5871/(781) 687-2317 

Contributors Annette Acosta, MN, Team Leader 

Kathy Gudgell, BSN 

Jeanne Martin, Pharm.D. 

Glen Pickens, BSN 

Sean Smith, Office of Investigations 
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA 

Appendix D 

VA Office of Inspector General 22 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA New England Healthcare System (10N1) 

Director, Edith Nourse Rogers Memorial Veterans Hospital (518/00) 

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: Edward M. Kennedy, John F. Kerry 

U.S. House of Representatives: John Tierney 

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