Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 08-02565-204

Combined Assessment Program 

Review of the 

VA Western New York 

Healthcare System 

Buffalo, New York 

August 31, 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 VA Western New York Healthcare System, Buffalo, New York 

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 

Environment of Care.......................................................................................... 5 

Physician Credentialing and Privileging............................................................. 7 

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

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

Magnetic Resonance Imaging Safety ................................................................ 10

VHA Satisfaction Surveys ....................................................................................... 11

Appendixes

A. VISN Director Comments .................................................................................. 13

B. System Director Comments............................................................................... 14

C. OIG Contact and Staff Acknowledgments ......................................................... 19

D. Report Distribution............................................................................................. 20

VA Office of Inspector General 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

Executive Summary 

Introduction During the week of July 13–17, 2009, the OIG conducted a 

Combined Assessment Program (CAP) review of the VA 

Western New York Healthcare System (the system), Buffalo, 

NY. 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 

200 system employees. The system is part of Veterans 

Integrated Service Network (VISN) 2. 

Results of the 

Review 

This CAP review covered six operational activities. We 

identified the following organizational strengths and reported 

accomplishments:

• Computer Assisted Design/Computer Assisted 

Manufacturing (CAD/CAM) dentistry. 

• Improved access to substance abuse (SA) treatment. 

We made recommendations in all six of the activities 

reviewed. For these activities, system managers needed to: 

• Ensure that implementation and efficacy of corrective 

actions identified through the root cause analysis (RCA) 

process are reported timely. 

• Ensure the analysis of system-wide patient complaint 

data for overall trends. 

• Monitor the use of the copy and paste functions and 

report trends to the Executive Committee of the Medical 

Staff (ECMS). 

• Correct identified infection control (IC) deficiencies at the 

Batavia division. 

• Ensure proper storage of oxygen cylinders at the Batavia 

division. 

• Ensure that professional practice evaluations are fully 

implemented for all privileged physicians and that ECMS 

minutes reflect discussions regarding performance data. 

• Ensure that discharge summaries and instructions 

include all required elements and that the information is 

consistent. 

• Require monthly medication reviews for all community 

living center (CLC) patients and monitor compliance. 

VA Office of Inspector General i
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

• Ensure that magnetic resonance imaging (MRI) 

screening forms be accessible timely in the computerized 

patient record system (CPRS) and that the forms contain 

complete patient identification information. 

This report was prepared under the direction of 

Jeanne Martin, Associate Director, Bedford Office of 

Healthcare Inspections. 

Comments The VISN and System Directors agreed with the CAP review 

findings and recommendations and provided acceptable 

improvement plans. (See Appendixes A and B, 

pages 13–18 for 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 VA Western New York Healthcare System, Buffalo, New York 

VA Office of Inspector General 1 

Introduction 

Profile Organization. The system provides a broad range of 

inpatient and outpatient health care services at two divisions 

located in Buffalo and Batavia, NY. Outpatient care is also 

provided at seven community based outpatient clinics 

(CBOCs) in Dunkirk, Lackawanna, Jamestown, Lockport, 

Olean, Niagara Falls, and Warsaw, NY. The system is part 

of VISN 2 and serves a veteran population of about 

100,000 throughout 10 counties in western New York. 

Programs. The Buffalo division provides comprehensive 

health care through primary care, acute care, (medicine, 

surgery, and mental health (MH)), and long-term care 

services. It is the main referral center for cardiac surgery, 

cardiology, and cancer care for central and western New 

York and northern Pennsylvania. 

The Batavia division provides primary care and long-term 

care services. It also has a male post-traumatic stress 

disorder (PTSD) residential unit and a female combined 

sexual trauma and PTSD residential unit. 

Affiliations and Research. The system is affiliated with the 

State University of New York at Buffalo’s School of Medicine 

and Biomedical Sciences and annually provides training for 

99 residents. It also provides training in other health care 

professions, such as audiology, dentistry, nursing,

pharmacy, health care administration, occupational and 

physical therapy, psychology, speech pathology, and social 

work. The system’s fiscal year (FY) 2009 research program 

has 200 approved projects and a budget of more than 

$4 million. Important areas of research include oncology, 

endocrinology, and pulmonary disease. 

Resources. In FY 2008, the system’s medical care 

expenditures totaled $197 million. FY 2008 staffing was 

1,690 full-time employee equivalents (FTE), including 

115 physician and 503 nursing FTE. 

Workload. In FY 2008, the system treated more than 

40,000 unique patients and provided over 37,300 inpatient 

days in the hospital. In addition, the system provided over 

36,300 inpatient days in the CLC1

 units. The inpatient care 

 

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 VA Western New York Healthcare System, Buffalo, New York 

workload totaled 4,768 discharges, and the average daily 

census (including CLC patients) was 201. Outpatient 

workload totaled more than 449,600 visits. 

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 six activities: 

• Coordination of Care.

• Environment of Care (EOC).

• Medication Management.

• MRI Safety.

• Physician Credentialing and Privileging (C&P).

• QM Program.

The review covered system operations for FY 2008 and 

quarter 1 of FY 2009 and was done in accordance with OIG 

standard operating procedures for CAP reviews. We also 

followed up on selected recommendations from our prior 

CAP review (Combined Assessment Program Review of the 

VA Western New York Healthcare System, Buffalo, New 

York, Report No. 05-03096-137, May 2, 2006). In that 

VA Office of Inspector General 2 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

report, we recommended that managers improve drainage in 

a shower on the SA residential rehabilitation unit. During our 

follow-up review, we found sufficient evidence that managers 

had implemented appropriate actions to address the 

recommendation, and we consider the issue closed. 

During this review, we also presented fraud and integrity 

awareness briefings for 200 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 made recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. 

Organizational Strengths 

Computer Assisted 

Design/Computer 

Assisted 

Manufacturing 

Dentistry 

The system’s Dental Service implemented CAD/CAM 

technology for the fabrication of ceramic dental crowns. This 

innovative technology allows dentists to fabricate and 

cement dental crowns in a single visit. Prior to the 

implementation of this technology, it took two to three 

separate dental visits over a 4–6 week period to complete 

the procedure utilizing conventional techniques. CAD/CAM 

technology has increased access to dental care and patient 

satisfaction. Additionally, the system realized a significant 

cost savings. During the period June 2008–June 2009, 

281 CAD/CAM crowns were fabricated for a total savings 

of $22,480. 

Improved Access 

to Substance 

Abuse Treatment 

Managers developed a system redesign initiative to improve 

access to SA treatment. Prior to implementation of the 

initiative, patients seeking SA treatment waited an average 

of 7–23 days to receive initial appointments for evaluation, 

which contributed to a high no-show rate. Additionally, 

consults for SA treatment took an average of 22 days to 

process. 

Managers initiated a walk-in intake process that allows 

providers to see patients seeking SA treatment the same day 

they present to the facility. Also, the intake providers 

process SA treatment consults daily. Since implementation 

in March 2009, the program has eliminated the waiting time 

for intake evaluations, decreased the no-show rate from 

VA Office of Inspector General 3 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

VA Office of Inspector General 4 

22 percent to 2 percent, and reduced the consult response 

time to 2–3 days. 

Results 

Review Activities With Recommendations 

Quality 

Management 

Program 

The purpose of this review was to evaluate whether the 

system 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, patient safety employees, and the QM 

Coordinator. 

The system’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 three areas that needed improvement. 

RCA Process. We found that RCA2 reviews were thorough. 

However, information from the Veterans Health 

Administration (VHA) National Center for Patient Safety 

(NCPS) database, known as SPOT (not an acronym), 

showed that between May 1, 2008, and June 30, 2009, 45 

percent of the identified corrective actions that were due had 

not been reported as implemented. Additionally, results of 

monitoring activity for 50 percent of the outcome measures 

that were due had not been reported. VHA regulations3

require that corrective actions identified through RCA 

reviews be implemented and monitored for efficacy. 

Patient Complaint Data. The system collected patient 

complaint data and appropriately referred issues to care line 

managers for resolution. However, there is an expectation in 

VHA regulations4

 that all complaints received throughout the 

organization will be analyzed for overall trends. At the time 

of our review, analysis of system-wide patient complaint data 

was not being conducted. 

 

2

 An RCA is an in-depth analysis of an adverse event to determine why the event occurred and to develop corrective 

actions to prevent future occurrences. 

3

 VHA Handbook 1050.01, VHA National Patient Safety Improvement Handbook, May 23, 2008. 4

 VHA Handbook 1003.4, Patient Advocacy Program, September 2, 2005. 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

VA Office of Inspector General 5 

Medical Record Documentation. VHA regulations5 and VISN 

policy require that managers monitor the copy and paste 

functions in CPRS for inappropriate use and report violations 

to the ECMS for corrective actions. While VHA requirements 

for monitoring have been in place since 2006, system 

managers did not begin monitoring the use of these 

functions until January 2009. Additionally, this information 

was not trended or provider specific; consequently, the data 

were not useful in the identification of system issues. 

Recommendation 1 We recommended that the VISN Director ensure that the 

System Director requires that implementation and efficacy of 

corrective actions identified through the RCA process be 

reported timely. 

Recommendation 2 We recommended that the VISN Director ensure that the 

System Director requires the analysis of system-wide patient 

complaint data for overall trends. 

Recommendation 3 We recommended that the VISN Director ensure that the 

System Director requires that managers monitor the use of 

the copy and paste functions and report trends to the ECMS. 

The VISN and System Directors agreed with the findings and 

recommendations. They reported that responsible care line 

managers will report the status of RCA action items to the 

Health Systems Committee until items are fully resolved. 

The patient advocate will analyze patient complaint data, and 

care line managers will develop action plans for problematic 

areas. The patient advocate will report trends and actions to 

the appropriate committee. The Directors also reported that 

Health Information Management managers will develop a 

process to monitor the use of the copy and paste functions 

and report monthly to the Medical Records Committee. 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 

system maintained a safe and clean health care 

environment. VHA facilities are required to establish a 

comprehensive EOC program that fully meets VHA, NCPS, 

Occupational Safety and Health Administration, National 

Fire Protection Association (NFPA), and accreditation 

requirements. At the Buffalo division, we inspected the 

 

5

 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

following areas: (a) two medical/surgical units, (b) the 

intensive care unit, (c) the acute MH unit, and (d) one CLC 

unit. At the Batavia division, we inspected three CLC units. 

The inspected areas were clean and well maintained, and 

nurse managers expressed satisfaction with the 

housekeeping staff assigned to their areas. We reviewed 

fire drill reports for April 2008–April 2009 and found that 

managers conducted fire drills as required and assessed 

personnel and equipment performance. Additionally, we 

determined that managers identified environmental hazards 

on the acute MH unit that potentially posed threats to 

patients. The system provided documentation of risk 

assessment and abatement tracking of safety issues 

previously identified on the unit, and unit staff completed 

suicide risk training. However, we identified two areas at the 

Batavia division that needed improvement. 

IC. VHA facilities are required to implement and maintain 

effective IC programs. To fully meet the requirement, 

emergency call cords should be made of materials (for 

example, vinyl or plastic) that can be cleaned and 

disinfected. Cloth or materials that absorb moisture can 

serve as a reservoir for microorganism growth. The cords 

should also be of a length that will prevent them from coming 

into contact with floor surfaces. On the three CLC units, we 

found call cords made of cloth in congregate and patient 

bathrooms, and the cords were touching the floors. While 

we were onsite, managers replaced the cloth cords with 

plastic ones, but the length of the replaced cords still allowed 

them to touch floor surfaces. 

Additionally, we found two storage rooms where clean linens 

and patient protective equipment were stored on the floor in 

plastic and paper bags. Clean items must be stored in 

appropriate containers that are not in contact with floor 

surfaces. 

Safety. The NFPA requires that oxygen cylinders be stored 

securely and in a location where they are protected from 

potential tampering and where heavy objects cannot strike or 

fall on them. On one CLC unit, we found that oxygen 

cylinders were stored in a corridor accessible to the public. 

VA Office of Inspector General 6 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

VA Office of Inspector General 7 

Recommendation 4 We recommended that the VISN Director ensure that the 

System Director corrects identified IC deficiencies at the 

Batavia division. 

Recommendation 5 We recommended that the VISN Director ensure that the 

System Director requires the proper storage of oxygen 

cylinders at the Batavia division. 

The VISN and System Directors agreed with the findings and 

recommendations. They reported that emergency pull cords 

made of cloth have been replaced with plastic cords and that 

the cords have been shortened to the appropriate length. 

They also reported that patient clothing and individual 

protective equipment will be stored on shelves and that 

oxygen cylinders were moved to a secured location for 

storage. The corrective actions are acceptable, and we 

consider these two recommendations closed. 

Physician 

Credentialing and 

Privileging 

The purpose of this review was to determine whether VHA 

facilities have consistent processes for physician C&P. For a 

sample of physicians, we reviewed selected VHA required 

elements in C&P files and provider profiles.6 We also 

reviewed meeting minutes during which discussions about 

the physicians took place. 

We reviewed 16 physicians’ C&P files and profiles. The 

physicians were either appointed to the medical staff or 

reprivileged by the medical staff in the past 12 months. We 

found that licenses to practice were current and that 

managers obtained appropriate primary source verification7

for all physicians reviewed. However, we identified an area 

that needed improvement. 

Professional Practice Evaluation. VHA regulations require 

that clinical managers develop thorough professional 

practice plans with specific competency criteria for all 

privileged physicians. Although clinical managers had 

developed service-specific criteria for professional practice 

evaluations at the time of our CAP review, implementation of 

the process did not commence until May 2009. 

Consequently, only 2 (13 percent) of the 16 physicians had 

adequate data to support the privileges granted. 

 

6

 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 7

 Primary source verification is documentation from the original source of a specific credential that verifies the 

accuracy of a qualification reported by an individual health care practitioner. 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

VA Office of Inspector General 8 

Additionally, ECMS meeting minutes did not reflect detailed 

discussions about performance data. 

Recommendation 6 We recommended that the VISN Director ensure that the 

System Director requires that professional practice 

evaluations for all privileged physicians are fully 

implemented and that ECMS minutes reflect discussions 

regarding performance data. 

The VISN and System Directors agreed with the findings and 

recommendation. They reported that all physician profile 

folders will contain professional practice evaluation data. 

Additionally, the ECMS will include discussions about 

professional practice data in meeting minutes and will submit 

quarterly reports to system leadership. The implementation 

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

actions until they are completed. 

Coordination of 

Care 

The purpose of this review was to evaluate whether inpatient 

intra-facility transfers, discharges, and post-discharge MH 

care were coordinated appropriately over the continuum of 

care and met VHA and accreditation standards. Coordinated 

transfers, discharges, and post-discharge MH care are 

essential to integrated care processes and optimal patient 

outcomes. 

We found that providers managed intra-facility transfers 

appropriately and that MH discharge documentation included 

follow-up MH appointments and information about 

emergency MH services. However, we identified an area 

that needed improvement. 

Discharges. VHA regulations8

 require that specific 

information be included in discharge summaries and 

discharge instructions. We reviewed 22 medical records and 

found that in 21 (95 percent) of the records, various 

elements required by VHA were missing in either the 

discharge summaries or the discharge instructions. This 

created inconsistencies between the summaries and the 

instructions. Additionally, when the elements were included 

in both documents, they were not always consistent. For 

example, we found five records where diet instructions 

differed between the summaries and the instructions. 

 

8

 VHA Handbook 1907.01. 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

VA Office of Inspector General 9 

Recommendation 7 We recommended that the VISN Director ensure that the 

System Director requires that discharge summaries and 

discharge instructions include all required elements and that 

information in the summaries and instructions is consistent. 

The VISN and System Directors agreed with the findings and 

recommendation. They reported that clinical managers will 

redesign the discharge summary template and discharge 

instruction note to include all required elements. They also 

reported that Health Information Management managers will 

monitor the use of the redesigned template and note for 

compliance and will report results quarterly. 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 

facilities had developed effective and safe medication 

management practices. We reviewed selected medication 

management processes on the medical/surgical, MH, and 

CLC units. 

The system had a designated Bar Code Medication 

Administration Program coordinator. Reassessments for 

154 administered doses of PRN9 pain medications reviewed 

for the period of April 26–May 3, 2009, were documented. 

However, we identified an area that needed improvement. 

Monthly Medication Reviews. System policy requires that 

pharmacists review the medications of all CLC residents 

each month. Our inspection covered the previous 

12 months. We reviewed five patients’ medical records on 

each of the three CLC units (a total of 60 required reviews 

per unit). We found that pharmacists completed all the 

monthly medication reviews on two of the three units. On 

the third unit, we found that only 46 (77 percent) of the 

required 60 monthly reviews were completed. 

Recommendation 8 We recommended that the VISN Director ensure that the 

System Director requires that pharmacists perform monthly 

medication reviews for all CLC patients and that compliance 

is monitored. 

The VISN and System Directors agreed with the findings and 

recommendation. They reported that pharmacists will review 

all CLC residents’ medications monthly and that pharmacy 

 

9

 PRN is a Latin abbreviation [L pro re nata] meaning as needed or as the circumstances require. 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

VA Office of Inspector General 10 

managers will monitor compliance and report findings to the 

appropriate committee quarterly. The implementation plans 

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

until they are completed. 

Magnetic 

Resonance 

Imaging Safety 

The purpose of this review was to evaluate whether the 

system maintained a safe environment and had safe practice 

procedures in the MRI area. Safe MRI procedures minimize 

risk to patients, visitors, and staff and are essential to quality 

patient care. 

We inspected the MRI area, examined medical and training 

records, reviewed relevant policies, and interviewed key 

personnel. We determined that the system had adequate 

safety policies and conducted a risk assessment of the 

environment, as required by The Joint Commission. The 

system had appropriate signage and barriers to prevent 

unauthorized or accidental access to the MRI area. Patients 

in the magnet room were directly observed at all times. 

Two-way communication was available between the patient 

and the MRI technologist, and the patient had access to a 

push-button call system while in the scanner. 

We reviewed the training records of five MRI personnel and 

found that all had completed appropriate safety training 

specific to their MRI zone level access. Additionally, we 

reviewed the training records of six support (non-MRI) 

personnel who had access to the MRI area and found that all 

had completed MRI safety training. However, we identified 

an area that needed improvement. 

Screening. All patients should undergo safety screening 

prior to MRI procedures.10 Radiology personnel record 

patient screening information on MRI screening forms that 

are later scanned into the patient’s medical record. We 

reviewed the medical records of 10 patients who received an 

MRI during a 3-day period 2 months prior to our visit. None 

of the electronic medical records contained the MRI 

screening form. We were unable to locate paper copies of 

the forms for four patients. Of the six forms we were able to 

locate, two did not contain complete patient identification 

information. In addition, we found forms from the past 

3 months that had not yet been scanned into patient records. 

 

10 VA Radiology, Online Guide, Sec. 4.3, MRI Safety, http://vaww1.va.gov/Radiology/page.cfm?pg=167. 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

Recommendation 9 We recommended that the VISN Director ensure that the 

System Director requires that MRI screening forms be 

accessible timely in CPRS and that the forms contain 

complete patient identification information. 

The VISN and System Directors agreed with the findings and 

recommendation. They reported that Radiology, Clinical 

Applications, and Information Systems managers will 

develop a process to ensure that MRI screening forms are 

completed and available. The implementation plans are 

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

they are completed. 

VHA Satisfaction Surveys 

VHA has identified patient and employee satisfaction scores as significant indicators of 

facility performance. Patients are surveyed monthly, and data are summarized 

quarterly. Figure 1 below and Figure 2 on the next page show the system, VISN, and 

national overall inpatient and outpatient satisfaction scores for FYs 2007 and 2008. 

Target scores are noted on the graphs. 

VA Office of Inspector General 11 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

Employees are surveyed annually. Figure 3 below shows the system’s overall 

employee scores for 2007, 2008, and 2009. Since no target scores have been 

designated for employee satisfaction, VISN and national scores are included for 

comparison. 

VA Office of Inspector General 12 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 13 

Department of 

Veterans Affairs Memorandum 

Date: August 13, 2009 

From: Director, VA Healthcare Network Upstate New York (10N2) 

Subject: Combined Assessment Program Review of the 

VA Western New York Healthcare System, Buffalo, 

New York

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

Director, Management Review Service (10B5) 

VISN 2 concurs in all findings and recommendations. 

 (original signed by:) 

STEPHEN L. LEMONS, Ed.D. 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

Appendix B 

System Director Comments 

VA Office of Inspector General 14 

Department of 

Veterans Affairs Memorandum 

Date: August 10, 2009 

From: Director, VA Western New York Healthcare System (528/00) 

Subject: Combined Assessment Program Review of the VA 

Western New York Healthcare System, Buffalo, 

New York

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

Director, Management Review Service (10B5) 

We concur with your findings and recommendations. 

 (original signed by:) 

WILLIAM F. FEELEY, MSW, FACHE 

 

 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

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 System Director requires that implementation and efficacy of 

corrective actions identified through the RCA process be reported timely. 

Concur Target Completion Date: 

RCA Actions/HSC Agenda – 8/13/09 

Qtly Rpt to LLC – 9/13/09 

Action Plan: Announcement of OIG Recommendation at Health Systems 

Committee meeting on 8/13/09. Health Systems Committee will include 

on agenda monthly RCA action items. Status of implementation 

monitoring to be reported monthly until resolution. Discussion and status 

will be documented in the Health System Committee minutes. Care Line 

Managers will assign manager responsible for assigned RCA action item. 

Chief of Staff will ensure that this is done. Report to be presented at Local 

Leadership Council (LLC) quarterly. 

Recommendation 2. We recommended that the VISN Director ensure 

that the System Director requires the analysis of system-wide patient 

complaint data for overall trends.

Concur Target Completion Date: 11/2/09 

Qtly Rpt to Accreditation Cmte & LLC 

Action Plan: The Patient Advocate will identify the Care Line Manager 

responsible for action plans of trended data reflecting problematic areas. 

Care Line Manager will return action plan to the Patient Advocate who will 

include attachment with the quarterly Patient Advocate report beginning 

4th Qtr FY 09. The Accreditation Care Planning Sub-Committee will 

review action plans and follow up actions and document status until 

resolution. Report to be presented at the Local Leadership Council 

quarterly with trended themes for improvement. 

VA Office of Inspector General 15 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

Recommendation 3. We recommended that the VISN Director ensure 

that the System Director requires that managers monitor the use of the 

copy and paste function and report trends to ECMS. 

Concur Target Completion Date:

Develop Review Process/Initiate Data Collection – 7/16/09

Qtrly Rpt to Accreditation Cmte & Leadership – 11/2/09 

Action Plan: The Health Information Management System (HIMS) 

Manager will develop a monthly review process to effectively monitor the 

importing/copying (copy/paste) of text into CPRS that allows for provider 

specific profiling. Beginning 7/1/09 the HIMS Manager will initiate data 

collection. Beginning with 4th Qtr FY 09 results, the HIMS Manager will 

report the trended outcomes quarterly to the Medical Records Committee. 

The Chair of the Medical Records Committee will forward provider specific 

data to the section chiefs. The section chiefs will review the results with 

the specific providers telling them to cease and desist the copy/past 

practice. The section chief will also include this data into the provider 

profiling package. Verification of discussion (memo format) with the 

individual provider will be sent to the Chair of the Medical Records 

Committee. The Chair of the Medical Records Committee or designee will 

report the copy/paste data and action outcomes to the Accreditation Care 

Planning Sub-Committee beginning with the 4th Qtr Report. A monthly 

report will also be presented to Leadership for the next 12 months. 

Recommendation 4. We recommended that the VISN Director ensure 

that the System Director corrects identified IC deficiencies at the Batavia 

division. 

Concur Completed Date: 7/16/09 

Action Plan: Cloth cords have been replaced with plastic cords that can 

be cleaned. The plastic cords have been shortened so they no longer 

touch the floor but could be reached if a patient were on the floor. Clean 

linens and patient protective equipment (patient clothing & individual 

protective equipment) will be stored on shelves in the Personal Clothing 

Room on ground floor. (Note: the clean linen was laundered patient 

clothing waiting for return to family). 

Recommendation 5. We recommended that the VISN Director ensure 

that the System Director requires proper storage of oxygen cylinders at 

the Batavia division. 

Concur Completed Date: 7/16/09 

VA Office of Inspector General 16 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

Action Plan: A room has been designated for storage on Oak Lodge to 

house oxygen cylinders safely to meet NFPA 99 standards. The room has 

capability for locking. Oxygen cylinders have been moved to the 

designated location. Oxygen cylinders have been added as a regular part 

of the Batavia EOC rounds checklist. 

Recommendation 6. We recommended that the VISN Director ensure 

that the System Director requires that professional practice evaluations for 

all privileged physicians are fully implemented and that ECMS minutes 

reflect discussions regarding performance data. 

Concur Target Completion Date: 

Discussion at ECMS – 8/13/09 

Qtrly Rpt to Leadership – 9/09 

Action Plan: Plans for professional practice evaluations have been in 

place since May 2009. Section chiefs are to ensure collection of focused 

and ongoing professional practice evaluation data for inclusion in provider 

profiling folders. Detailed discussion of all physician performance data 

prior to privileging will be included in the ECMS meeting minutes 

beginning August 2009. A report will be presented to Leadership 

quarterly. 

Recommendation 7. We recommended that the VISN Director ensure 

that the System Director requires that discharge summaries and discharge 

instructions include all required elements and that information in the 

summaries and instructions is consistent. 

Concur Target Completion Date: 10/1/09 

Action Plan: Health Information Management System (HIMS) Manager to 

review VHA Handbook 1907.01 to identify the required elements of the 

discharge summary and discharge instruction note. HIMS Manager will 

communicate results of this review to the Chief of Staff (COS). The COS 

will redesign the discharge summary template to include all required 

elements. The Nurse Executive and COS will redesign the discharge 

instruction note to include all required elements. The COS will investigate 

with CAC the possibility of designing a discharge order set that includes all 

discharge instruction note requirements. COS will investigate the 

capability of discharge order set required elements being automatically 

dropped into the discharge instruction note. Education for providers and 

RN nursing staff will be completed by 10/1/09. Beginning with 10/1/09 

discharges the HIMS Manager will collect data on provider specific 

compliance with required documentation elements for discharge summary 

and discharge instruction note and report to the Medical Record 

Committee quarterly. 

VA Office of Inspector General 17 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

VA Office of Inspector General 18 

Recommendation 8. We recommended that the VISN Director ensure 

that the System Director requires that pharmacists perform monthly 

medication reviews for all CLC patients and that compliance is monitored.

Concur Target Completion Date: 

Medication Reviews/Documentation in Pharmacy 

Review Note/Tracking of Compliance – 7/16/09 

Qtrly Rpt to Accreditation Cmte – 10/5/09 

Action Plan: All CLC residents medication regimen will be reviewed each 

month by a pharmacist beginning 7/2009. This medication review must be 

documented in the monthly pharmacy review note. The Pharmacy 

Manager will monitor compliance by the CLC Pharmacist and unit. The 

Pharmacy Manager will include tracking and trending results in the 

Medication Management quarterly report to the Accreditation Care 

Planning Sub-Committee beginning with 7/2009 reviews. The first 

committee report will be presented on 10/5/2009. 

Recommendation 9. We recommended that the VISN Director ensure 

that the System Director requires that MRI screening forms be accessible 

timely in CPRS and that the forms contain complete patient identification 

information. 

Concur Target Completion Date: 9/15/2009 

Action Plan: The Radiology Manager will meet with the Clinical 

Applications Coordinator to investigate/develop the capability of IMED 

system to incorporate the MRI safety questionnaire into the system. If 

IMED system is unable to include MRI safety questionnaire Information 

Systems (IS) will need to provide signature pads and supporting software. 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

Appendix C 

VA Office of Inspector General 19 

OIG Contact and Staff Acknowledgments 

Contact Jeanne Martin, Associate Director 

Bedford Office of Healthcare Inspections 

(603) 222-5872 

Contributors Annette Acosta, MN 

Kathy Gudgell, BSN 

Katherine Owens, MSN 

Glen Pickens, BSN 

Jenny Walenta, Office of Investigations 
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York 

Appendix D 

VA Office of Inspector General 20 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Healthcare Network Upstate New York (10N2) 

Director, VA Western New York Healthcare System (528/00) 

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: Kirsten E. Gillibrand, Charles E. Schumer 

U.S. House of Representatives: Christopher J. Lee, Louise Slaughter 

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