Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 09-03313-59

Combined Assessment Program 

Review of the 

Phoenix VA Health Care System 

Phoenix, Arizona 

January 11, 2010

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 Phoenix VA Health Care System, Phoenix, Arizona 

Table of Contents 

Page 

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

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

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

Objectives and Scope ............................................................................................. 1

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

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

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

Medication Management ................................................................................... 4

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

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

Coordination of Care ......................................................................................... 6

Magnetic Resonance Imaging Safety ................................................................ 6

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

Quality Management ......................................................................................... 7

VHA Satisfaction Surveys ....................................................................................... 8

Appendixes

A. VISN Director Comments .................................................................................. 10

B. System Director Comments ............................................................................... 11

C. OIG Contact and Staff Acknowledgments ......................................................... 14

D. Report Distribution ............................................................................................. 15

VA Office of Inspector General 
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona 

Executive Summary 

Introduction During the week of October 26–30, 2009, the OIG conducted 

a Combined Assessment Program (CAP) review of the 

Phoenix VA Health Care System (the system), Phoenix, AZ. 

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 

302 system employees. The system is part of Veterans 

Integrated Service Network (VISN) 18. 

Results of the 

Review 

The CAP review covered six operational activities. We 

identified the following organizational strengths and reported 

accomplishments: 

• Managing Veterans’ Belongings. 

• Podiatry Access. 

We made recommendations in two of the activities reviewed. 

For these activities, the system needed to: 

• Require that nurses consistently document PRN (as 

needed) pain medication effectiveness in the Bar Code 

Medication Administration (BCMA) record within the 

timeframe specified by local policy. 

• Require that the Information Safety Officer (ISO) 

consistently attend environment of care (EOC) rounds. 

The system complied with selected standards in the following 

four activities: 

• Coordination of Care (COC). 

• Magnetic Resonance Imaging (MRI) Safety. 

• Physician Credentialing and Privileging (C&P). 

• QM. 

This report was prepared under the direction of 

Linda G. DeLong, Director, Dallas Office of Healthcare 

Inspections. 

VA Office of Inspector General i
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona 

VA Office of Inspector General ii

Comments The VISN and System Directors agreed with the CAP review 

findings and recommendations and submitted acceptable 

improvement plans. (See Appendixes A and B, pages 

11–14, 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 Phoenix VA Health Care System, Phoenix, Arizona 

Introduction 

Profile Organization. The system is a tertiary care facility located 

in Phoenix, AZ, that provides a broad range of inpatient and 

outpatient health care services. Outpatient care is also 

provided at seven community based outpatient clinics in 

Phoenix, Mesa, Buckeye, Payson, Globe, Sun City, and 

Show Low, AZ. The system is part of VISN 18 and serves a 

veteran population of about 321,400 throughout the Arizona 

counties of Maricopa, Gila, and Navajo. 

Programs. The system provides medical, surgical, mental 

health (MH), geriatric, rehabilitation, and diagnostic services. 

It has 197 hospital beds and 104 community living center 

(CLC) beds. 

Affiliations and Research. The system is affiliated with the 

University of Arizona’s College of Medicine (in partnership 

with Arizona State University) and with the multidisciplinary 

Phoenix Independent Residency Programs. It provides 

training for 83 residents in medicine, surgery, and psychiatry. 

In fiscal year (FY) 2009, the system research program had 

110 projects and a budget of approximately $3 million. 

Important areas of research included diabetes, obesity, 

gastroenterology, nephrology, podiatry, and drug utilization.

Resources. In FY 2009, medical care expenditures totaled 

$397 million. (The medical care budget was $400 million.) 

FY 2009 staffing was 2,499 full-time employee equivalents 

(FTE), including 240 physician and 506 nursing FTE. 

Workload. In FY 2009, the system treated 75,071 unique 

patients and provided 29,444 inpatient days in the hospital 

and 22,515 inpatient days in the CLC units. The inpatient 

care workload totaled 5,416 discharges, and the average 

daily census, including CLC patients, was 142. Outpatient 

workload totaled 688,447 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.

VA Office of Inspector General 1 
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona 

• 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: 

• COC.

• EOC.

• Medication Management.

• MRI Safety.

• Physician C&P.

• QM.

The review covered system operations for FY 2009 and 

FY 2010 through October 26, 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 of the system (Combined 

Assessment Program Review of the Carl T. Hayden VA 

Medical Center, Phoenix, Arizona, Report No. 07-00282-140, 

June 1, 2007). The system had corrected all findings related 

to health care from our prior CAP review. 

During this review, we also presented fraud and integrity 

awareness briefings for 302 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 

VA Office of Inspector General 2 
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona 

are implemented. Activities in the “Review Activities Without 

Recommendations” section have no reportable findings.

Organizational Strengths 

Managing 

Veterans’ 

Belongings 

The “Bag & Tag” system was implemented in an effort to 

safely and accurately secure patient clothing, valuables, 

luggage, and effects upon admission. The old process 

required that nursing admissions staff complete a detailed 

inventory, which was burdensome and impinged on patient 

care time. This led to errors in inventory, unverifiable claims, 

and frustrated patients. A team was assembled, and its 

goals were to simplify the process for patients and staff to 

reduce errors, claims, and staff time and to improve security 

and customer satisfaction. 

The revised process has each veteran secure their own 

belongings in a bag; admissions staff witness and oversee 

the process. During the first year, implementation of this 

system resulted in a 54 percent reduction in total clothing 

room claims and a reduction of 1,309 staff time hours (an 

estimated value of $37,464). In addition, there were no theft 

or loss claims.

Podiatry Access Timely access to the podiatry clinic was identified as a 

concern primarily due to delays, missed opportunities, and 

patient flow issues. Using system redesign principles, an 

in-depth analysis was initiated by podiatry clinic staff 

(physician, nurses, and support staff), and root causes of the 

inefficiencies were identified. 

Changes to the process included: 

• Modifying the scheduling package to prevent overload 

at 8 a.m. and 1 p.m. 

• Providing patients with the clinic phone number to 

request appointment cancellations. 

• Completing preliminary clinical requirements at the 

time of the consult. 

• Instituting reminder phone calls 2 days prior to 

appointments. 

• Providing alternatives to face-to-face visits (for 

example, mail delivery of prosthetic devices). 

• Discontinuing automatic rescheduling of “no shows.” 

VA Office of Inspector General 3 
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona 

• Seeing patients who arrive late to appointments 

instead of rescheduling. 

• Improving telephone consultation process. 

• Discharging patients back to primary care. 

As a result of these changes, the podiatry clinic now 

maintains a 99 percent rate for new patient visits within 

30 days. Also, missed opportunities are rare (2 percent). 

Results 

Review Activities With Recommendations 

Medication 

Management 

The purpose of this review was to evaluate whether the 

system had developed effective and safe medication 

management practices. We reviewed selected medication 

management processes in the inpatient medical (which 

includes oncology and spinal cord injury), inpatient surgical, 

telemetry, medical intensive care, surgical intensive care, 

and short stay units and in two MH and two CLC units. 

We reviewed documentation provided and found that the 

designated BCMA Program Coordinator had appropriately 

identified and addressed problems. In addition, pharmacists 

consistently performed and documented monthly medication 

reviews for all 10 CLC unit residents whose records we 

reviewed. However, we identified the following area that 

needed improvement. 

Pain Medication Effectiveness Documentation. Local policy 

requires that nurses assess and document the effectiveness 

of PRN pain medications in the BCMA record using a pain 

score within 240 minutes of administration. We reviewed the 

BCMA records of 50 patients who received a total of 

158 doses of PRN pain medications. We found that 

133 (84 percent) of the 158 doses administered had 

effectiveness documented within the timeframe specified by 

local policy. 

Recommendation 1 We recommended that the VISN Director ensure that the 

System Director requires that nurses consistently document 

PRN pain medication effectiveness in the BCMA record 

within the timeframe specified by local policy. 

The VISN and System Directors concurred with the finding 

and recommendation. On November 30, 2009, nursing staff 

VA Office of Inspector General 4 
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona 

initiated hourly rounds to assess and document PRN pain 

medication effectiveness. Documentation will be monitored 

monthly, and results will be reported to the Nursing Quality 

Council and reviewed by the Patient Care Services Quality 

Council. Any trends and required actions will be reported to 

the Performance Improvement Board and the Executive 

Quality Council. The corrective actions are acceptable, and 

we consider this recommendation closed. 

Environment of 

Care 

The purpose of this review was to determine if VHA facilities 

maintained a safe and clean health care environment. VHA 

facilities are required to establish a comprehensive EOC 

program that fully meets VHA, National Center for Patient 

Safety, Occupational Safety and Health Administration, 

National Fire Protection Association, and Joint Commission 

(JC) standards. 

We inspected the inpatient medical, inpatient surgical, MH, 

medical intensive care, surgical intensive care, hemodialysis, 

and CLC units. We also inspected the outpatient clinic; the 

emergency department; the supply, processing, and 

distribution department; the pulmonary and gastroenterology 

clinics; and the prosthetics and sleep laboratories. The 

system maintained a generally clean and safe environment. 

However, we identified the following condition that needed 

improvement. 

EOC Rounds. EOC rounds conducted by the system’s 

inspection team allow each discipline participating to identify 

and correct discrepancies, unsafe working conditions, and 

other regulatory violations. Representation from each 

discipline enables the team to cover the system in depth. A 

Deputy Under Secretary for Health for Operations and 

Management memorandum issued on March 5, 2007, 

requires the ISO to be included as a team member on EOC 

rounds. The ISO or the ISO’s designee participated in 

20 (67 percent) of 30 weekly EOC rounds. 

Recommendation 2 We recommended that the VISN Director ensure that the 

System Director requires that the ISO consistently participate 

in EOC rounds. 

The VISN and System Directors concurred with the finding 

and recommendation. Since October 1, 2009, the ISO has 

attended all EOC rounds. EOC rounds attendance is 

reported at the monthly EOC Committee meetings, and any 

trends will be addressed by the Associate Director. The 

VA Office of Inspector General 5 
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona 

corrective actions are acceptable, and we consider this 

recommendation closed. 

Review Activities Without Recommendations 

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 JC requirements. Coordinated 

transfers, discharges, and post-discharge MH care are 

essential to an integrated, ongoing care process and optimal 

patient outcomes. 

We reviewed the documentation for 21 intra-facility transfers 

and determined that clinicians appropriately managed all 21. 

We found transfer notes from sending to receiving units and 

documentation that nursing assessments were performed by 

the receiving units in accordance with established 

timeframes. 

We reviewed the medical records of 20 patients who were 

discharged and found that all patients received appropriate 

written discharge instructions. We also found documentation 

that the patients understood those instructions. 

Additionally, we reviewed the medical records of six patients 

recently discharged from the acute MH units. We found 

documentation that patients received information about 

accessing emergency MH care and that patients were given 

MH clinic appointments within 2 weeks of discharge. We 

also found documentation that MH providers either arranged 

for follow-up appointments or contacted the patients by 

phone within 7 days of discharge. We made no 

recommendations. 

Magnetic 

Resonance 

Imaging Safety 

The purpose of this review was to evaluate whether the 

system maintained a safe environment and safe practices 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 had appropriately conducted a risk 

assessment of the environment, as required by The JC. 

VA Office of Inspector General 6 
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona 

VA Office of Inspector General 7 

The system had appropriate signage and barriers to prevent 

unauthorized or accidental access to the MRI area. Patients 

in the magnet room are directly observed at all times. 

Two-way communication is available between the patient 

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

push-button call system while in the scanner. 

Additionally, mock fire and emergency response drills have 

been conducted in the MRI area. 

Local policy requires that personnel who have access to the 

MRI area receive appropriate MRI safety training. We 

reviewed the training records of 12 personnel and found that 

all had completed required safety training. 

We reviewed the medical records of 10 patients who 

received an MRI. In all cases, patients received appropriate 

screening. In addition, five patients who had an MRI with 

contrast media had signed informed consents prior to their 

procedures, in accordance with local policy. We made no 

recommendations. 

Physician 

Credentialing and 

Privileging 

The purpose of this review was to determine whether VHA 

facilities have consistent processes for C&P physicians. For 

a sample of physicians, we reviewed selected VHA required 

elements in C&P files and physician profiles.1 We also 

reviewed meeting minutes during which discussions about 

the physicians took place. 

We reviewed 10 C&P files and profiles and found that 

licenses were current and that primary source verification 

had been obtained. Focused Professional Practice 

Evaluation was appropriately implemented for newly hired 

physicians. Service-specific criteria for Ongoing 

Professional Practice Evaluation had been developed and 

approved. We found sufficient performance data to meet 

current requirements. Meeting minutes consistently 

documented thorough discussions of the physicians’ 

privileges and performance data prior to recommending 

renewal of or initial requested privileges. We made no 

recommendations. 

Quality 

Management 

The purpose of this review was to evaluate whether the 

system’s QM program provided comprehensive oversight of 

the quality of care and whether senior managers actively 

supported the program’s activities. We interviewed the 

 

1

 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona 

VA Office of Inspector General 8 

system’s Director and Chief of Staff, and we interviewed QM 

personnel. We evaluated plans, policies, performance 

improvement data, and other relevant documents. 

The system’s QM program was effective and well managed. 

Senior managers supported the program through 

participation in and evaluation of performance improvement 

initiatives and through allocation of resources to the 

program. Meaningful data were analyzed, trended, and 

utilized to improve patient care. We made no 

recommendations.

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 shows the system’s and VISN’s overall inpatient satisfaction 

scores for quarters 1, 2, and 3 of FY 2009. Figure 2 on the next page shows the 

system’s and VISN’s overall outpatient satisfaction scores for quarter 3 of FY 2009.2

Target scores are noted on the graphs. 

 

2 Due to technical difficulties with VHA’s outpatient survey data, outpatient satisfaction scores for quarters 1 and 2 

of FY 2009 are not included for comparison.
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona 

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 9 
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 10 

Department of 

Veterans Affairs Memorandum 

Date: December 4, 2009

From: Director, VA Southwest Health Care Network (10N18) 

Subject: Combined Assessment Program Review of the Phoenix 

VA Health Care System, Phoenix, Arizona 

To: Director, Dallas Healthcare Inspections Division (54DA) 

Director, Management Review Service (10B5) 

I concur with the facility response to the recommendations for 

improvement contained in the Combined Assessment Program review of 

the Phoenix VA Health Care System, Phoenix, Arizona. For questions, 

please contact Joan Funckes, Executive Assistant to the Network Director, 

VISN 18 at (602) 222-2699. 

 (original signed by:) 

SUSAN P. BOWERS 
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona 

Appendix B 

System Director Comments 

VA Office of Inspector General 11 

Department of 

Veterans Affairs Memorandum 

Date: December 1, 2009 

From: Director, Phoenix VA Health Care System (644/00) 

Subject: Combined Assessment Program Review of the Phoenix 

VA Health Care System, Phoenix, Arizona 

To: Director, VA Southwest Health Care Network (10N18) 

1. The recommendations made during the Office of Inspector 

General Combined Assessment Program Review conducted 

October 26–30, 2009, have been reviewed, and implementation plans 

and subsequent actions have been completed. 

2. We would like to commend the OIG CAP Review Team that 

conducted our review. The team, led by Dr. Wilma Reyes including 

members Karen Moore, Marilyn Walls, Stephanie Hills, Cathleen King, 

Warren Porter, and Linda DeLong, was consultative and professional 

and provided excellent feedback to our staff. 

3. If you have any questions, please contact Sally Compton, QM Program 

Manager, Quality Management Department at (602) 277-5551 

ext. 6777. 

(original signed by:)

GABRIEL PÉREZ 

Medical Center Director 
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona 

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 nurses consistently document PRN 

pain medication effectiveness in the BCMA record within the timeframe 

specified by local policy. 

Concur 

Facility Response: During the week of November 2, 2009, appropriate 

procedures to document PRN pain medication effectiveness in the BCMA 

record within the timeframe specified by local policy (4 hours) were 

discussed by Nurse Managers with staff administering pain medications. 

Effective November 30, 2009, nursing staff initiated hourly rounds for 

nursing units where nursing staff assess PRN effectiveness for patients 

who have received pain medications within the last hour and will 

document PRN effectiveness when rounds are completed. Monitoring of 

PRN pain medication effectiveness documentation will be conducted 

monthly by nursing staff as part of charts audits with results reported to 

the Nursing Quality Council and reviewed by the Patient Care Services 

Quality Council. Trends and any required actions will be reported to the 

facility Performance Improvement Board and Executive Quality Council. 

We recommend this item be closed. 

Target Completion Date: Completed 

Recommendation 2. We recommended that the VISN Director ensure 

that the System Director requires that the ISO consistently participate in 

EOC rounds. 

Concur 

Facility Response: The System Director discussed the requirement for 

the facility Information Security Officer to attend Environment of Care 

Rounds with the VISN ISO on November 2, 2009. EOC Rounds 

attendance records are maintained by the facility’s Safety Specialist, and 

beginning October 1, 2009, the facility ISO has attended all EOC Rounds 

to date. EOC Rounds attendance is reported at the monthly EOC 

VA Office of Inspector General 12 
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona 

VA Office of Inspector General 13 

Committee, and any trends will be addressed by the Associate Director 

who is the EOC Committee chairperson, with follow up to the System 

Director or VISN ISO, as appropriate. 

We recommend this item be closed. 

Target Completion Date: Completed 
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona 

Appendix C 

VA Office of Inspector General 14 

OIG Contact and Staff Acknowledgments 

Contact Linda G. DeLong, Director 

Dallas Office of Healthcare Inspections 

(214) 253-3331 

Contributors Wilma Reyes, Team Leader 

Laura Dulcie 

Stephanie Hills 

Cathleen King 

Karen Moore 

Warren Porter 

Marilyn Walls 

Richard Cady, Office of Investigations 

Diana Cahill, Office of Investigations 

John Waugh, Office of Investigations 
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona 

Appendix D 

VA Office of Inspector General 15 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Southwest Health Care Network (10N18) 

Director, Phoenix VA Health Care System (644/00) 

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: Jon Kyl, John McCain 

U.S. House of Representatives: Ed Pastor 

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