Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 08-01446-93

Combined Assessment Program 

Review of the 

Tennessee Valley Healthcare System 

Nashville, Tennessee 

March 10, 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 Tennessee Valley Healthcare System, Nashville, TN 

Table of Contents 

Page 

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

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

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

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

Results ....................................................................................................................... 3

Review Activities With Recommendations ............................................................. 3

Quality Management ........................................................................................ 3

Emergency/Urgent Care Operations ................................................................ 6

Medication Management .................................................................................. 7

Review Activities Without Recommendations ........................................................ 8

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

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

Pharmacy Operations....................................................................................... 9

Staffing ............................................................................................................. 10

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

Appendixes

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

B. System Director Comments.............................................................................. 15

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

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

VA Office of Inspector General 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

Executive Summary 

Introduction During the week of August 11–15, 2008, the OIG conducted 

a Combined Assessment Program (CAP) review of the 

Tennessee Valley Healthcare System (the system), 

Nashville, TN. The purpose of the review was to evaluate 

selected operations, focusing on patient care administration 

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

provided fraud and integrity awareness training to 

158 system employees. The system is part of Veterans 

Integrated Service Network (VISN) 9. 

Results of the 

Review 

The CAP review covered eight operational activities. We 

made recommendations in three of the activities reviewed; 

one was a repeat recommendation from our previous CAP 

review. For these activities, the system needed to: 

• Complete a comprehensive review of the QM Department 

to redesign the processes used to capture, trend, analyze, 

document, correct, and follow up required QM activities. 

• Ensure that competency folders for emergency department 

(ED) registered nurses (RNs) are updated. 

• Ensure consistent documentation of pain medication 

effectiveness within required timeframes. 

The system complied with selected standards in the following 

five activities: 

• Coordination of Care. 

• Environment of Care (EOC). 

• Pharmacy Operations. 

• Staffing. 

• Survey of Healthcare Experiences of Patients (SHEP). 

This report was prepared under the direction of 

Victoria Coates, Director, Atlanta Office of Healthcare 

Inspections. 

VA Office of Inspector General i
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

VA Office of Inspector General ii

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 14–18, 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 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

VA Office of Inspector General 1 

Introduction 

Profile Organization. The system is a tertiary, integrated health 

care system comprised of medical centers located in 

Nashville (NV) and Murfreesboro (MU), TN. It provides a 

broad range of inpatient and outpatient health care services. 

Outpatient care is also provided at nine community based 

outpatient clinics (CBOCs) in Arnold Air Force Base, 

Chattanooga, Clarksville, Cookeville, Dover, and Nashville 

(two CBOCs), TN, and in Fort Campbell and Bowling Green, 

KY. The system is part of VISN 9 and serves a veteran 

population of about 560,000 throughout middle Tennessee 

and southern Kentucky. 

Programs. The system provides ambulatory, medical, 

surgical, and transplant services; spinal cord injury outpatient 

care; and a full range of extended care and mental health 

services. The NV campus is the only VA facility that 

supports all solid organ transplant programs, including 

kidney and bone marrow transplants. The MU campus is a 

VISN referral center for mental health, geriatrics, and 

extended care services. The system has 256 hospital beds 

and 245 community living center (CLC)1

 beds. 

Affiliations and Research. The system is affiliated with 

Meharry Medical College and Vanderbilt University’s School 

of Medicine and provides instruction for 806 trainees, 

including surgery and medical residents, dental students, 

and allied health students. In fiscal year (FY) 2007, the 

system research program had 254 projects and a budget of 

$18.1 million. (FY 2008 data was not available at the time of 

our review.) Important areas of research include cancer, 

diabetes, and post-traumatic stress disorder. 

Resources. In FY 2007, medical care expenditures totaled 

$372 million. FY 2007 staffing was 2,938 full-time employee 

equivalents (FTE), including 245 physician and 649 nursing 

FTE. (FY 2008 data was not available at the time of our 

review.) 

Workload. In FY 2007, the system treated 86,514 unique 

patients and provided 67,822 inpatient days in the hospital 

and 67,767 inpatient days in the CLC. The inpatient care 

workload totaled 919 discharges, and the average daily 

 

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 Tennessee Valley Healthcare System, Nashville, TN 

census, including CLC patients, was 371.5. Outpatient 

workload totaled 656,276 visits. (FY 2008 data was not 

available at the time of our review.) 

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/Urgent Care Operations.

• EOC.

• Medication Management.

• Pharmacy Operations.

• QM.

• SHEP.

• Staffing.

The review covered system operations for FY 2007 and 

FY 2008 through August 15, 2008, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. We also followed up on select recommendations 

from our prior CAP review of the system (Combined 

VA Office of Inspector General 2 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

Assessment Program Review of the VA Tennessee Valley 

Healthcare System, Nashville, Tennessee, Report 

No. 05-02298-65, January 30, 2006). The system had not 

corrected all findings related to trending and analysis of 

performance improvement (PI) data identified in our previous 

CAP review (see page 5). 

During this review, we also presented fraud and integrity 

awareness briefings to 158 employees. These briefings 

covered procedures for reporting suspected criminal activity 

to the OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. The activities in the “Review Activities 

Without Recommendations” section have no findings 

requiring corrective actions.

Results 

Review Activities With Recommendations 

Quality 

Management 

The purposes of this review were to determine if the system 

(a) had a comprehensive and effective QM program 

designed to monitor patient care activities and coordinate 

improvement efforts and (b) complied with Veterans Health 

Administration (VHA) directives, appropriate accreditation 

standards, and Federal and local regulations. To evaluate 

QM processes, we interviewed senior managers, QM staff, 

and other knowledgeable staff. In addition, we reviewed the 

QM self-assessment regarding compliance with QM 

requirements as well as committee minutes and other 

relevant QM documents. We also followed up on 

recommendations made in the previous CAP report to 

determine the effectiveness of corrective actions. 

We found that the QM program did not provide the 

necessary monitoring and oversight to assure that some 

patient care processes were safe and effective, and as a 

result, opportunities for improvement may not have been 

identified and addressed. While we found that credentialing 

and privileging, patient safety, National Patient Safety Goals, 

operative and other invasive procedures, and patient 

complaints were monitored appropriately, we determined 

that eight additional areas were not monitored in accordance 

VA Office of Inspector General 3 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

VA Office of Inspector General 4 

with policy. A ninth area, utilization management, had not 

been monitored adequately in the past; however, monitoring 

recently improved. Therefore, we did not include this area in 

our list of deficiencies. 

Overall, we found limited structure and accountability in 

relation to quality monitoring and PI efforts in the eight 

program areas. The deficiencies generally fell into one of 

the following categories: 

Completeness of Quality Management Program Monitors. 

QM program monitors need to include specific elements to 

evaluate QM activities. Accreditation standards, VHA 

policies,2 and local policies require monitoring of QM 

activities to identify trends and patterns resulting in 

improvement initiatives. 

Documentation of Corrective Actions and Follow-Up. 

Identified QM improvement initiatives require documentation 

of corrective actions and follow-up plans. Accreditation 

standards, VHA policies,3

 and local policies define the 

processes and systems necessary to document planned 

corrective actions and follow-up to ensure that actions taken 

are effective. 

Reporting to and/or Evaluation by an Oversight Committee. 

Accreditation standards, VHA policies,4

 and local policies 

require routine evaluation of important QM monitors by an 

oversight committee to ensure that improvement 

opportunities are evaluated and that appropriate actions are 

implemented. 

Trending and Analysis of Data. Accreditation standards, 

VHA policies,5

 and local policies provide guidance on PI data 

trending and analysis expectations. Trending and analysis 

are necessary to identify improvement opportunities by 

evaluating the significance of the trends and analyzing the 

data. 

 

2

 VHA Directive 2005-056, Mortality Assessment, December 1, 2005; VHA Handbook 1907.01, Health Information 

Management and Health Records, August 25, 2006; VHA Directive 2008-004, Peer Review for Quality 

Management, January 28, 2008; and VHA Directive 2008-002, Disclosure of Adverse Events to Patients, 

January 18, 2008. 

3

 Ibid. 

4

 Ibid. 

5

 Ibid. 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

This was a repeat finding from our previous CAP review. In 

that review, we found that although the system collected PI 

data, it was not consistently trended and analyzed. The 

system reported that they would develop a method for 

trending and analyzing PI data to correct the condition. 

However, during this review we found that the PI issues 

identified in our previous CAP review continued to exist. 

The table below illustrates the extent to which the various 

types of deficiencies spanned multiple QM program areas. 

QM MONITOR AREA 

Incomplete QM monitors (not all required elements present) Inadequate actions and follow-up Inadequate reporting to and/or evaluation by an oversight committee Inadequate data trending and analysis 

Mortality Review and Analysis X X 

Medical Records Review X X X 

System Redesign/Patient Flow X 

Peer Review X X X 

Adverse Event Disclosure X 

Blood and Blood Products Review X X 

Moderate Sedation X 

Restraint and Seclusion X X 

We believe that redesign of the basic program monitoring 

structure for QM is needed to promote communication and 

information sharing and to comply with VHA and external 

accreditation standards. This action would likely improve the 

deficiencies we found in the individual program monitoring 

areas. 

Recommendation 1 We recommended that the VISN Director ensure that the 

System Director requires that QM experts complete a 

comprehensive review of the QM Department to redesign the 

processes used to capture, trend, analyze, document, 

correct, and follow up required QM activities. 

The VISN and System Directors concurred with the findings 

and recommendation. A comprehensive review of the 

committee organizational structure, including a review of QM 

components, is in progress. This review is expected to result 

VA Office of Inspector General 5 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

in improved QM committee structure and quality monitoring 

activities. The improvement plans are acceptable, and we 

will follow up on the completion of the planned actions. 

Emergency/Urgent 

Care Operations 

The purposes of this review were to evaluate the cleanliness 

and safety of the system’s EDs and to determine compliance 

with VHA guidelines related to hours of operation, clinic 

capability (including management of patients with acute 

mental health diagnoses and patients transferred to other 

facilities), and staff competency. We evaluated ED EOC, 

and we interviewed ED directors and nurse managers. 

The system has an ED located at each campus. Both are 

open the required 24 hours per day, 7 days per week. We 

found that the ED services provided were within the system’s 

capability. In addition, we found that the system was in the 

process of drafting a diversion policy to manage patients 

transferred to other facilities. In the interim, system staff 

reported that they follow admission policies and do not divert 

patients to other hospitals. 

We found that local policy did not address the procedure to 

follow if an ED employee failed a required competency. 

System staff reported that there are plans to amend the 

policy to include this component. While there had not been 

any instances of staff failing a required unit-based 

competency, nursing managers were able to verbalize 

procedures to follow if this occurred. Therefore, we did not 

make a recommendation in this area. We identified one area 

that needed improvement. 

Emergency Department Registered Nurse Competencies. 

We reviewed competency folders for three ED RNs at each 

campus and found that three NV folders did not contain 

evidence of annual position-specific competencies, as 

required by local policy. In addition, we found that one MU 

folder contained an expired Advanced Cardiac Life Support 

certification, which was out of compliance with local policy. 

Recommendation 2 We recommended that the VISN Director ensure that the 

System Director requires that all ED RN competency folders 

be updated and maintained in accordance with local policy. 

The VISN and System Directors concurred with the findings 

and recommendation. The system has reviewed and 

updated all ED RN competency folders and documented the 

plan to maintain the folders, including competency 

VA Office of Inspector General 6 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

verification forms, in accordance with local policy. The 

improvement plans are acceptable, and we will follow up on 

the completion of the planned actions. 

Medication 

Management

The purpose of this review was to evaluate whether VHA 

facilities had adequate medication management practices. A 

safe medication management system includes medication 

ordering, administering, and monitoring. 

We reviewed selected medication management processes in 

the inpatient medical, surgical, intensive care, mental health, 

and transitional care units at the NV and MU campuses. We 

found adequate management of medications brought into the 

facility by patients or their families. Nurses appropriately 

scanned patient armbands and ensured correct identification 

of patients prior to medication administration. We identified 

one area that needed improvement. 

Documentation of Pain Medication Effectiveness. We found 

that on the units we reviewed, nurses did not consistently 

document the effectiveness of PRN (as needed) pain 

medications, as required by local policy. We assessed the 

Bar Code Medication Administration records for 

32 patients hospitalized at the time of our visit. From 

August 4–11, 2008, nurses administered 272 doses of PRN 

pain medications to these patients. However, they did not 

document the effectiveness of 130 (48 percent) of the 

272 doses within 4 hours, as required by local policy. (The 

longest time span from administration to documentation of 

effectiveness exceeded 3 days.) Without appropriate 

follow-up and consistent documentation, clinicians could not 

be assured that patients’ pain was effectively managed. 

Recommendation 3 We recommended that the VISN Director ensure that the 

System Director requires consistent documentation of pain 

medication effectiveness within the required timeframe. 

The VISN and System Directors concurred with the finding 

and recommendation. The system has implemented an 

action plan, which includes daily tracking of reports on PRN 

medication effectiveness and individual performance 

monitoring by nurse managers. The improvement plans are 

acceptable, and we will follow up on the completion of the 

planned actions. 

VA Office of Inspector General 7 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

Review Activities Without Recommendations 

Coordination of 

Care 

The purpose of this review was to evaluate whether inpatient 

consultations, intra-facility transfers, and discharges were 

coordinated appropriately and met VHA and external 

accreditation standards. Coordinated consultations, 

transfers, and discharges are essential to optimal patient 

outcomes. 

We reviewed 12 inpatient consultations, 12 intra-facility 

transfers, and 12 discharges. In general, we found timely 

consultative services, appropriate nursing and physician 

transfer notes, consistency between discharge orders and 

discharge summaries, and sufficient documentation of 

patient discharge instruction education. We made no 

recommendations. 

Environment of 

Care 

The purpose of this review was to determine if the system 

complied with selected infection control standards and 

maintained a safe and clean patient care environment. VHA 

facilities are required to establish a comprehensive EOC 

program that fully meets VA National Center for Patient 

Safety, Occupational Safety and Health Administration, and 

Joint Commission standards. 

At the MU campus, we inspected the mental health, CLC, 

intensive care, and transitional care units and the dental 

clinic. At the NV campus, we inspected the acute care, 

mental health, dialysis, and intensive care units; the 

gastroenterology lab; four primary care clinics; the substance 

abuse outpatient clinic; and the dental clinic. We found that 

the system was generally clean and well maintained. The 

infection control program monitored exposures and reported 

data to clinicians to improve performance. 

During our EOC tours, we identified several conditions 

requiring management attention. The following are the 

issues we identified and the actions taken while we were 

onsite. 

• We found that 6 (20 percent) of the 30 medication and 

nourishment refrigerators required cleaning. All six 

refrigerators were cleaned, and staff verbalized the 

plan to monitor the refrigerators to ensure future 

cleanliness. 

VA Office of Inspector General 8 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

• We found a telephone with exposed electrical wires in 

a mental health unit staff break room. The telephone 

was removed. 

• We found unsecured portable oxygen tanks. The 

oxygen tanks were temporarily secured, and a 

replacement holding rack was ordered. 

• We found long blade scissors on a medication cart 

during a medication pass on the locked mental health 

unit. The inspector voiced her concern that these 

could be dangerous to the unit’s patient population. In 

response, the scissors were replaced with a safer 

alternative. 

In addition, at the NV campus, we found 13 corrugated 

cardboard boxes in the Nutrition and Food Service’s food 

preparation and tray line areas. VHA policy addresses the 

need to keep corrugated cardboard to a minimum within the 

kitchen area to maintain pest and infection control. While we 

were onsite, managers removed the corrugated cardboard 

boxes and planned to identify alternative storage containers. 

We also evaluated the status of deficiencies identified on the 

system’s July 1, 2008, Mental Health Environment of Care 

Checklist. The checklist serves as a tool for documentation 

and tracking of identified environmental safety concerns. We 

found that, in general, the system had taken appropriate 

corrective actions. In cases where conditions could not be 

immediately corrected (for example, structural renovations 

were required), the system implemented Interim Life Safety 

Measures pending completion of permanent corrections. We 

made no recommendations. 

Pharmacy 

Operations 

The purposes of this review were to evaluate whether VA 

health care facilities had adequate controls to ensure the 

security and proper management of controlled substances 

and to evaluate the safety and security of the inpatient and 

outpatient pharmacies’ internal physical environments. We 

also assessed whether clinical managers had processes in 

place to monitor patients for polypharmacy. 

We assessed whether the system’s policies and practices 

were consistent with VHA regulations governing pharmacy 

and controlled substances security. We inspected inpatient 

and outpatient pharmacies for security, EOC, and infection 

VA Office of Inspector General 9 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

control, and we interviewed appropriate Pharmacy Service 

and Police and Security Service personnel. 

Pharmacy Controls. Our review showed that the system had 

appropriate policies and procedures to ensure the security of 

controlled substances and to ensure the safety and security 

of the pharmacies’ internal physical environments. The 

system’s Controlled Substances Coordinator (CSC) 

implemented actions when necessary, and training records 

showed that the CSC and controlled substances inspectors 

received appropriate training to execute their duties. Any 

identified discrepancies had been followed up in accordance 

with VHA policy. We also found that managers reported all 

controlled substances diversions or suspected diversions to 

the OIG. The pharmacies were secure, clean, and well 

maintained. 

Polypharmacy. Pharmacological regimens involving multiple 

medications are often necessary to prevent and control 

disease states; however, excessive use of medications can 

result in adverse reactions and increased risk 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. 

We found that managers had developed effective processes 

and monitors to ensure that clinical pharmacists identified 

patients who were prescribed multiple medications, reviewed 

their medication regimens to avoid polypharmacy, and 

advised providers as appropriate. We made no 

recommendations. 

Staffing The purpose of this review was to evaluate whether the 

system had developed comprehensive staffing guidelines 

and whether the guidelines had been met. We found that 

the system had developed adequate staffing guidelines 

using hours per patient day and hours per shift. 

We reviewed actual staffing for 22 inpatient units, the two 

EDs, and four specialty areas. We found that the system’s 

approved guidelines for nurse staffing were generally met in 

all areas reviewed. In addition, we found that specific 

VA Office of Inspector General 10 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

actions had been taken to ensure safe patient care, including 

the use of contract licensed practical nurses and nursing 

assistants. We made no recommendations. 

Survey of 

Healthcare 

Experiences of 

Patients 

SHEP is aimed at capturing patient perceptions of care in 

12 service areas, including access to care, coordination of 

care, and courtesy. VHA relies on the Office of Quality and 

Performance’s analysis of the survey data to improve the 

quality of care delivered to patients. 

VHA’s Executive Career Field Performance Plan states that 

at least 76 percent of inpatients discharged during a 

specified date range and 77 percent of outpatients treated 

will report the overall quality of their experiences as “very 

good” or “excellent.” Facilities are expected to address 

areas in which they are underperforming. The purpose of 

this review was to assess the extent that VHA facilities used 

SHEP data to improve patient care, treatment, and services. 

The graphs on the next page show the system’s 

performance in relation to national and VISN performance. 

Figure 1 shows the system’s SHEP performance measure 

results for inpatients, and Figure 2 shows the system’s 

SHEP performance measure results for outpatients. 

VA Office of Inspector General 11 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

60

65

70

75

80

85

90

95

100

Qtr 3 (FY 06) 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)

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

Facility

VISN

National

TENNESSEE VALLEY HEALTHCARE SYSTEM

INPATIENT OVERALL QUALITY

BY QUARTER

Meets 

Target

Figure 1:

60

65

70

75

80

85

90

95

100

Qtr 3 (FY 06) 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)

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

Facility

VISN

National

TENNESSEE VALLEY HEALTHCARE SYSTEM

OUTPATIENT OVERALL QUALITY

BY QUARTER

Figure 2:

Meets 

Target

VA Office of Inspector General 12 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

VA Office of Inspector General 13 

The system’s inpatient and outpatient overall SHEP scores 

for the 3rd quarter of FY 2006 through the 2nd quarter of 

FY 2008 did not meet established targets for 6 of the 

8 quarters. We were told that previous program managers 

had not aggressively managed the SHEP program. 

At the time of our visit, we found that the system’s 

multidisciplinary Veteran Satisfaction Improvement 

Committee (VSIC) adequately analyzed and reported SHEP 

survey results and addressed deficiencies. New SHEP 

program managers educated service chiefs on 

service-specific patient satisfaction issues and required 

service chiefs to submit corrective action plans and follow up 

when indicated. In addition, the VSIC was working to 

improve patient satisfaction through enhanced telephone 

services, expansion of offsite clinic access, staff education 

regarding patient satisfaction issues, and deployment of 

customer service “ambassadors” to patient care areas. The 

system continues to review the effectiveness of its actions 

and make modifications as needed. Since internal 

satisfaction scores have shown improvement, we made no 

recommendations.
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 14 

Department of 

Veterans Affairs Memorandum 

Date: February 23, 2009 

From: Director, VA Mid South Healthcare Network (10N9) 

Subject: Combined Assessment Program Review of the 

Tennessee Valley Healthcare System, Nashville, 

Tennessee 

To: Director, Atlanta Office of Healthcare Inspections (54AT) 

Director, Management Review Service (10B5) 

1. I concur with the findings and recommendations of this Office of 

Inspector General Combined Assessment Program Review of the 

Tennessee Valley Healthcare System, Nashville, Tennessee, as well as 

the action plan developed by the facility. 

2. If you have questions or require additional information from the 

Network, please do not hesitate to contact Pamela Kelly, Staff Assistant to 

the Network Director, at 615-695-2205 or me at 615-695-2206. 

(original signed by:) 

John Dandridge, Jr. 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

Appendix B 

System Director Comments 

VA Office of Inspector General 15 

Department of 

Veterans Affairs Memorandum 

Date: February 20, 2009 

From: Director, Tennessee Valley Healthcare System (626/00) 

Subject: Combined Assessment Program Review of the 

Tennessee Valley Healthcare System, Nashville, 

Tennessee 

To: Director, VA Mid South Healthcare Network (10N9) 

Director, Management Review Service (10B5) 

1. On behalf of the Tennessee Valley Healthcare System, Nashville, 

Tennessee, I concur with the findings and recommendations of this Office 

of Inspector General report. We had already been actively working to 

improve or enhance several of these areas and welcome the “fresh eyes” 

perspective provided by this report. 

2. Included herein is an outline of improvement actions already taken, in 

progress, or planned in response to these findings. We believe these 

changes will further enhance key systems and processes in healthcare 

system. 

(original signed by:) 

Juan Morales, RN 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

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 QM experts complete a 

comprehensive review of the QM Department to redesign the processes 

used to capture, trend, analyze, document, correct, and follow up required 

QM activities. 

CONCUR 

TVHS Response: A retired Quality Manager expert who is under contract 

has completed a comprehensive review of the committee organizational 

structure, including a review of many of the QM components identified by 

the Combined Assess Program (CAP) review. 

For each organizational committee, this individual is researching VHA, VA, 

VISN, and TVHS references. She then composes memos to the 

chairperson of each committee detailing inconsistencies with current 

practice and required processes including: 

1. Composition of membership 

2. Attendance rates 

3. Quality monitoring activities 

4. Documentation requirements including: 

• collection of data 

• trending of data 

• analysis of data 

• utilization of data to effect improvements 

• evidence of corrective actions 

• follow-up plans 

• reporting timeframes to the oversight committee 

Sample agendas and reporting schedules for each required element are 

developed. Instructions are provided for the expected "Reporting Format" 

for quality monitoring activities to include the use of charts to better 

VA Office of Inspector General 16 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

ascertain progress toward goals. Minutes of all committees will be 

monitored periodically to assure that all requirements are accomplished. 

TVHS policy, Committee Minutes: Preparation, Submission and 

Distribution, was approved by the Governing Council on 

February 11, 2009. This policy details the documentation and reporting 

expectations. 

Memos as described above have been completed for 16 committees, 

including the following QM monitor areas identified in the table on page 5 

of the report: 

1. Medical Records Review 

2. System Redesign/Patient Flow (Quality Executive Board) 

3. Moderate Sedation 

4. Restraint and Seclusion (Quality Executive Board) 

5. Memo will be completed for Blood and Blood Products Review (Tissue 

and Transfusion Committee) by February 27, 2009. 

A review of Peer Review was conducted in conjunction with a review of 

the Risk Manager work processes. Consultation and advice relating to 

follow-up, trending, and analysis of data were provided to the Risk Manger 

who manages this program by the Interim Quality Manager and the 

contract individual. Reporting timeframes to the oversight committee 

(Clinical Management Board) have been established. 

Reporting time frames to the oversight committee (Clinical Management 

Board) have been established for Mortality Review and Analysis. 

References will be evaluated by February 27 to ensure all required 

elements are being addressed. 

Restraint and Seclusion reporting has been established to the oversight 

committee (Quality Executive Board). Instructions for trending and 

analysis of data have been provided to the Chief Nurse who collects the 

data. 

Follow-up responsibility for each of these areas will be assigned to QM 

specialists for tracking, analysis, and recommendations as appropriate. 

Recommendation 2. We recommended that the VISN Director ensure 

that the System Director require that all ED RN competency folders be 

updated and maintained in accordance with local policy. 

CONCUR 

TVHS Response: TVHS has completed review of all Emergency 

Department competency folders which have been updated and will be 

VA Office of Inspector General 17 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

VA Office of Inspector General 18 

maintained in accordance with system policy. Competency verification 

forms have been updated according to revised TVHS policy. 

Recommendation 3. We recommended that the VISN Director ensure 

that the System Director requires consistent documentation of pain 

medication effectiveness within the required timeframe. 

CONCUR 

TVHS Response: Following CAP review, the following action plan has 

been implemented: (1) Daily tracking and monitoring of reports from 

BCMA Coordinators on PRN effectiveness; (2) Staff are receiving training 

on BCMA documentation of PRN effectiveness. Target date for 

completion 3/15/09; (3) Since CAP visit, TVHS compliance is being 

monitored and tracked by Nursing Service daily. Follow-up to appropriate 

Nurse Managers regarding individual performance or compliance is 

ongoing daily; (4) Noon clinical huddle has been active; however, since 

December, the topic of PRN effectiveness has been added and is 

discussed daily. There is a project leader identified that disseminates 

information and recommendations from the clinical huddle to improve 

performance for PRN effectiveness; (5) Nursing service reviewed list of 

PRN medications and revised the list based on appropriate effectiveness 

within the 4 hour timeframe. 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

Appendix C 

VA Office of Inspector General 19 

OIG Contact and Staff Acknowledgments 

Contact Victoria Coates, Director 

Atlanta Office of Healthcare Inspections 

(404) 929-5961 

Contributors Toni Woodard, Team Leader 

Nancy Albaladejo 

Audrey Collins 

Melanie Cool 

Tishanna McCutchen 

Rick Ellison, Office of Investigations 
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, TN 

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 Mid South Healthcare Network (10N9) 

Director, Tennessee Valley Healthcare System (626/00) 

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: Lamar Alexander, Bob Corker 

U.S. House of Representatives: Jim Cooper, Bart Gordon 

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