Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 08-02986-67

Combined Assessment Program 

Review of the Northern Arizona 

VA Health Care System 

Prescott, Arizona 

February 5, 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 Northern Arizona VA Health Care System, Prescott, AZ 

Table of Contents 

Page 

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

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

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

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

Organizational Strength............................................................................................. 3

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

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

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

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

Emergency/Urgent Care Operations ................................................................. 7

Review Activities Without Recommendations ......................................................... 9

Coordination of Care ......................................................................................... 9

Pharmacy Operations and Controlled Substances Inspections......................... 9

Quality Management ......................................................................................... 10

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

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 Northern Arizona VA Health Care System, Prescott, AZ 

Executive Summary 

Introduction During the week of October 14–17, 2008, the OIG conducted 

a Combined Assessment Program (CAP) review of the 

Northern Arizona VA Health Care System (the system), 

Prescott, 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 

presented fraud and integrity awareness training to 

266 system employees. The system is part of Veterans 

Integrated Service Network (VISN) 18. 

Results of the 

Review 

The CAP review covered eight operational activities. We 

identified the following organizational strength and reported 

accomplishment: 

• Professional Practice Evaluation. 

We made recommendations in three of the activities 

reviewed. For these activities, the system needed to: 

• Specify an appropriate timeframe in the local policy for 

documentation of pain medication effectiveness. 

• Consistently document pain medication effectiveness in a 

timely manner. 

• Label items in medication refrigerators in accordance with 

accreditation standards. 

• Include the participation of the Information Security Officer 

(ISO) in environment of care (EOC) rounds, as required. 

• Display suicide prevention posters and brochures in highly 

visible areas throughout the system. 

• Maintain storage areas properly and secure sharp 

instruments. 

• Conduct EOC rounds more frequently in the emergency 

department (ED) and address any deficiencies identified. 

The system complied with selected standards in the following 

five activities: 

• Coordination of Care. 

• Pharmacy Operations and Controlled Substances (CS) 

Inspections. 

• QM. 

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

• Staffing. 

• Survey of Healthcare Experiences of Patients (SHEP). 

This report was prepared under the direction of 

Linda G. DeLong, Director, and Karen Moore, Associate 

Director, Dallas 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 14–18, for the full text of the Directors’ comments.) 

We will follow up on the planned action for 

Recommendation 4 until it is 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 Northern Arizona VA Health Care System, Prescott, AZ 

VA Office of Inspector General 1 

Introduction 

Profile Organization. The system provides a continuum of primary 

and secondary level medical, rehabilitative, and long-term 

care to veterans residing in northern Arizona. Also, primary 

level ambulatory care, screening services, and mental health 

services are provided through five community based 

outpatient clinics located in Kingman, Lake Havasu City, 

Bellemont, Cottonwood, and Anthem, AZ. The system is 

part of VISN 18 and serves a veteran population of about 

67,000 throughout a primary service area that includes parts 

of five counties in northern Arizona. 

Programs. The system provides primary and secondary 

inpatient medicine and ambulatory care, including general 

medicine, ambulatory surgery, mental hygiene, and selected 

specialized medical clinics. Rehabilitative care consists of a 

four-bed inpatient physical medicine rehabilitation unit with 

an active rehabilitation therapy department, an outpatient 

substance abuse treatment program, and a vocational 

rehabilitation/job training program. Long-term care consists 

of a community living center (CLC),1

 a geriatric evaluation 

and management program, and domiciliary care. Dementia, 

hospice, and respite programs are available within the CLC. 

Affiliations and Research. The system is affiliated with 

Midwestern University’s Arizona College of Osteopathic 

Medicine for 30-day rotations (clerkships) for third and fourth 

year medical students. The system also provides clinical 

training opportunities for nursing and allied health care 

professions through affiliations with several other 

universities. Currently, the system does not conduct 

research. 

Resources. In fiscal year (FY) 2008, medical care 

expenditures totaled $118 million. The FY 2009 medical 

care budget is projected to be $122 million. FY 2008 staffing 

was 725 full-time employee equivalents (FTE), including 

28 physician and 219 nursing FTE. 

Workload. In FY 2008, the system treated 23,002 unique 

patients and provided 7,453 inpatient days in the hospital, 

22,245 inpatient days in the CLC, and 30,923 inpatient days 

in the domiciliary. The inpatient care workload totaled 

 

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 Northern Arizona VA Health Care System, Prescott, AZ 

2,104 discharges, and the average daily census, including 

CLC and domiciliary patients, was 166. Outpatient workload 

totaled 237,706 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 eight activities: 

• Coordination of Care. 

• Emergency/Urgent Care Operations. 

• EOC. 

• Medication Management. 

• Pharmacy Operations and CS Inspections. 

• QM. 

• SHEP. 

• Staffing. 

The review covered system operations for FYs 2007, 2008, 

and 2009 through October 14, 2008, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. We also followed up on recommendations from our 

prior CAP review of the system (Combined Assessment 

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

Program Review of the Northern Arizona VA Health Care 

System, Prescott, Arizona, Report No. 04-02331-17, 

November 2, 2005). In that report, we identified 

improvement opportunities for colorectal cancer 

management. During the follow-up review, we found 

sufficient evidence that managers had implemented 

appropriate actions to address the identified deficiencies, 

and we consider the issue closed. 

During this review, we also presented fraud and integrity 

awareness briefings for 266 employees. These briefings 

covered procedures for reporting suspected criminal activity 

to the OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. Activities in the “Review Activities Without 

Recommendations” section have no reportable findings.

Organizational Strength 

Professional 

Practice Evaluation 

The system had specific forms and processes to collect, 

aggregate, and monitor provider-specific data. This is a 

Joint Commission (JC) requirement for focused and ongoing 

professional practice evaluation. 

The system uses general information applicable to all 

providers and specific data for each discipline. The 

information collected includes: (a) peer review "triggers" and 

non-protected peer review data; (b) six areas of general 

competencies defined by The JC; (c) provider-specific data 

customized to each discipline (such as blood utilization data, 

mortality, pharmacy, tort claims, non-protected peer reviews, 

patient complaints/compliments, utilization management 

data, clinical reminder reports, suicide data); and (d) clinical 

pertinence chart reviews (specific to each specialty). The 

information is aggregated every 6 months for each provider. 

Other VA facilities have sought to use this model. 

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

VA Office of Inspector General 4 

Results 

Review Activities With Recommendations 

Medication 

Management 

The purpose of this review was to evaluate whether 

Veterans Health Administration (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 telemetry and intensive care unit, the acute medical unit, 

and the CLC (CLC I and CLC II). We found appropriate use 

of patient armbands to correctly identify patients prior to 

medication administration. However, we identified the 

following areas that needed improvement. 

Pain Medication Effectiveness. VHA regulations2

 and local 

policy require that the effects of pain medications be 

monitored. Local policy did not define an appropriate 

timeframe for documentation of pain medication 

effectiveness. We reviewed 19 patient records for 

documentation of pain medication effectiveness. We noted 

that 112 (76 percent) of 148 administered doses of pain 

medications were documented for effectiveness. Also, we 

found that the times between pain medication administration 

and documentation of patient response to the medication 

ranged from 1 minute to 185 hours. Without appropriate 

documentation and follow-up, clinicians could not be assured 

that patients’ pain was effectively managed. 

Unlabeled Medication. Accreditation standards require that 

medications brought into the system by patients’ families be 

safely managed. In the medication refrigerator on CLC I, we 

found two unlabeled alcoholic beverages. There was a 

written doctor’s order, and the patient’s family had supplied 

the beverages. However, there were no labels on the bottles 

to identify ownership in order to monitor usage and ensure 

safe management. While we were onsite, the pharmacy 

supplied bar code labels to affix to the bottles. 

Recommendation 1 We recommended that the VISN Director ensure that the 

System Director requires local policy to specify an 

 

2

 VHA Directive 2003-021, Pain Management, May 2, 2003. 
Combined Assessment Program Review of the Northern Arizona VA Health Care System, Prescott, AZ 

appropriate timeframe for documentation of pain medication 

effectiveness. 

The VISN and System Directors agreed with the CAP review 

finding and recommendation. The system revised the local 

policy to specify that pain medication effectiveness must be 

evaluated within 1 hour for medications given orally and 

within 30 minutes for medications given intravenously. 

Effectiveness will be documented by the end of the shift in 

which the medication is administered. The corrective action 

is acceptable, and we consider this recommendation closed. 

Recommendation 2 We recommended that the VISN Director ensure that the 

System Director requires clinicians to consistently document 

pain medication effectiveness in a timely manner. 

The VISN and System Directors agreed with the CAP review 

finding and recommendation. They reported that all licensed 

practitioners who administer pain medications are 

responsible for documenting administration and 

effectiveness in the Bar Code Medication Administration 

system in a timely manner. A daily medication effectiveness 

report will be monitored by the nurse manager, or designee, 

of each unit. Each unit will report monthly to the Clinical 

Inpatient Service Line manager of their respective unit. The 

compliance requirement will be 100 percent. The corrective 

action is acceptable, and we consider this recommendation 

closed. 

Recommendation 3 We recommended that the VISN Director ensure that the 

System Director requires that items in medication 

refrigerators are labeled. 

The VISN and System Directors agreed with the CAP review 

findings and recommendation. They reported that the issue 

identified during the CAP review was resolved immediately. 

All items now placed in medication refrigerators by 

non-pharmacy staff will be labeled with full patient 

identification information. The corrective action is 

acceptable, and we consider this recommendation closed. 

Environment of 

Care 

The purpose of this review was to determine if the system 

maintained a safe and clean health care environment. The 

system is required to provide a comprehensive EOC 

program that fully meets VA National Center for Patient 

Safety, Occupational Safety and Health Administration 

(OSHA), and JC standards. The infection control (IC) 

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

program was evaluated to determine compliance with VHA 

directives based on the management of data collected and 

processes in which the data was used to improve 

performance. 

We inspected the telemetry and intensive care unit, the 

acute medical unit, the CLC, the domiciliary, two primary 

care clinics, and specialty clinics. The system maintained a 

generally clean environment. The IC program monitored and 

reported data to clinicians for implementation of quality 

improvements. However, we identified the following 

conditions that needed improvement. 

Environment of Care Rounds. EOC rounds conducted by 

the system’s inspection team allow each discipline 

participating on the team 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, and 

participation by each discipline’s representative or designee 

should be documented. A Deputy Under Secretary for 

Health for Operations and Management (DUSHOM) 

memorandum issued on March 5, 2007, requires the ISO to 

be included as a team member on EOC rounds. The ISO 

was not represented on EOC rounds. 

Suicide Prevention Information. A DUSHOM memorandum 

issued on December 7, 2007, requires suicide prevention 

posters and brochures to be displayed in highly visible areas 

throughout the system. During our review, we found two 

posters displayed in the primary care clinics and one 

displayed in the domiciliary. We were informed that suicide 

prevention posters had been recently received; however, 

they were not consistently displayed in highly visible areas 

throughout the system. 

Equipment Storage. According to OSHA, aisles and 

passageways in storage areas should be kept free of 

obstruction. Throughout the system, we observed that 

rooms designated as storage areas had excessive amounts 

of equipment, materials, and supplies. We found that the 

inpatient units utilized empty patient rooms, bathrooms, and 

a shower room for storage. The items being stored, such as 

a treatment cart, a dirty laundry cart, clean linen carts, and 

blood pressure monitoring devices, were used for daily care. 

Other equipment stored included fans, beds, scales, 

medication carts, a television, computer stands, and extra 

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

wheelchairs. Also, on CLC II, the door to a patient room only 

opened halfway due to an excessive amount of equipment. 

Unsecured Sharp Instruments. Sharp instruments should be 

secured in an effort to minimize risks and provide a safe 

environment for patients, staff, and visitors. A treatment cart 

on CLC I was unlocked and contained four pairs of scissors. 

Recommendation 4 We recommended that the VISN Director ensure that the 

System Director requires that the ISO participate in EOC 

rounds. 

The VISN and System Directors agreed with the CAP review 

finding and recommendation. They reported that the ISO will 

participate in EOC rounds. The improvement plan is 

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

planned action. 

Recommendation 5 We recommended that the VISN Director ensure that the 

System Director requires that suicide prevention posters and 

brochures are displayed in highly visible areas throughout 

the system. 

The VISN and System Directors agreed with the CAP review 

findings and recommendation. They reported that an 

additional 30 suicide posters were placed throughout the 

facility while the CAP review team was onsite. The 

corrective action is acceptable, and we consider this 

recommendation closed. 

Recommendation 6 We recommended that the VISN Director ensure that the 

System Director requires that storage areas are maintained 

properly and that sharp instruments are secured. 

The VISN and System Director agreed with CAP review 

findings and recommendation. They reported that a 

centralized equipment storage area has been established. 

Also, every clinical area throughout the facility will keep 

treatment carts locked and sharp items secured at all times 

that carts are not under the immediate supervision of facility 

staff. The corrective actions are acceptable, and we 

consider this recommendation closed. 

Emergency/Urgent 

Care Operations 

The purpose of this review was to evaluate whether VHA 

facility emergency/urgent care operations complied with VHA 

guidelines related to hours of operation, clinical capability 

(including management of patients with acute mental health 

VA Office of Inspector General 7 
Combined Assessment Program Review of the Northern Arizona VA Health Care System, Prescott, AZ 

conditions and patients transferred to other facilities), staffing 

adequacy, and staff competency. In addition, we inspected 

the system’s ED and triage environments for cleanliness and 

safety. 

The system’s ED is open 24 hours per day, 7 days per week, 

as required for an ED. It is located within the main hospital 

building, and emergency services provided are within the 

system’s patient care capabilities. In addition, the system 

had an appropriate policy for managing patients whose care 

may exceed the facility’s capability. 

We reviewed the medical records of patients who presented 

in the ED with acute mental health conditions and found that 

patients were managed appropriately. In addition, we 

determined that patient transfers complied with applicable 

policy. 

We reviewed the ED nurse staffing plan and time schedules 

and determined that managers had consistently followed 

their established staffing guidelines for allocating nursing 

resources. We also found that managers had appropriately 

documented nursing competencies. However, we found one 

area that needed improvement. 

Emergency Department Environment of Care Rounds. We 

conducted EOC rounds in the ED and the triage area and 

found space to be limited. During our rounds, we found two 

functional wall oxygen flow meters in the patient waiting area 

that were unattended. In the clean linen room, we found 

sterile bottles for an upcoming procedure on the floor in a 

biohazard container and clean laundry bags on top of dirty 

garbage cans. In addition, inpatient examination rooms were 

being utilized for equipment storage. While we were onsite, 

managers immediately corrected the deficiencies found 

during ED EOC rounds. 

Recommendation 7 We recommended that the VISN Director ensure that the 

System Director requires staff to conduct more frequent ED 

EOC rounds and address any deficiencies identified. 

The VISN and System Directors agreed with CAP review 

findings and recommendation. They reported that any extra 

equipment in the ED or the triage area is now removed daily 

and stored in the centralized storage area. The ED nurse 

manager has instituted daily EOC rounds in the ED to 

identify and resolve issues immediately. The corrective 

VA Office of Inspector General 8 
Combined Assessment Program Review of the Northern Arizona VA Health Care System, Prescott, AZ 

VA Office of Inspector General 9 

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 

consultations, intra-facility (ward-to-ward) transfers, and 

discharges were coordinated appropriately over the 

continuum of care and met local, VHA, and JC requirements. 

Coordinated consultations, transfers, and discharges are 

essential to an integrated, ongoing care process resulting in 

optimal patient outcomes. 

We reviewed the medical records of nine inpatients who had 

consults ordered and performed internally. In general, we 

found that inpatients received consultative services within 

acceptable timeframes. 

We determined that clinicians appropriately managed nine of 

nine intra-facility transfers. We found transfer notes from 

sending units to receiving units and documentation that 

nursing assessments were performed by the receiving units 

in accordance with established timeframes. 

We reviewed nine medical records of discharged patients 

and found that all patients received appropriate written 

discharge instructions. We also found documentation 

indicating that the patients understood the instructions. We 

made no recommendations. 

Pharmacy 

Operations and 

Controlled 

Substances 

Inspections 

The purpose of this review was to evaluate whether VHA 

facilities had adequate controls to ensure pharmacy security 

and proper management of CS. We also determined 

whether processes were in place to monitor polypharmacy 

(patients prescribed multiple medications), especially in 

vulnerable populations. 

We reviewed VHA regulations governing pharmacy and CS 

security, and we assessed whether the system’s policies and 

practices were consistent with VHA regulations.3

 We 

inspected inpatient and outpatient pharmacies for security, 

EOC, and IC concerns, and we interviewed appropriate 

Pharmacy Service and Police and Security Service 

 

3

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

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

May 30, 2006; VHA Handbook 1108.6, Inpatient Pharmacy, June 27, 2006. 
Combined Assessment Program Review of the Northern Arizona VA Health Care System, Prescott, AZ 

VA Office of Inspector General 10 

personnel as necessary. Additionally, we reviewed policies 

and procedures and interviewed appropriate personnel to 

determine if clinical pharmacists monitored patients 

prescribed multiple medications to avoid polypharmacy. 

Pharmacy Controls. Our review showed that the system had 

appropriate policies and procedures to ensure the security of 

the pharmacies and CS. CS inspections were conducted 

according to VHA regulations. Training records showed that 

the CS Coordinator (CSC), the alternate CSC, and all 

12 inspectors received appropriate training to execute their 

duties. The pharmacies’ internal environments were secure, 

clean, and well maintained. The biosafety cabinet, where 

sterile intravenous medications were prepared, complied 

with VHA regulations4 and IC standards. 

Polypharmacy. Pharmacological regimens involving multiple 

medications are often necessary to prevent and maintain 

disease states; however, excessive use of medications can 

result in adverse reactions and increased risks of 

complications. Polypharmacy is more complex than just the 

number of drugs that patients are prescribed. The clinical 

criteria to identify polypharmacy are the use of: 

(a) medications that have no apparent indication, 

(b) therapeutic equivalents to treat the same illness, 

(c) medications that interact with other prescribed drugs, 

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

treat adverse drug reactions.5

 Some literature suggests that 

that elderly patients and mental health patients are among 

the most vulnerable populations for polypharmacy.6

Our review showed that managers had developed effective 

processes 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. 

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 

 

4

 VHA Handbook 1108.6. 

5

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

December 2004. 

6

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

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

January 2006. 
Combined Assessment Program Review of the Northern Arizona VA Health Care System, Prescott, AZ 

supported the program’s activities. We interviewed the 

system’s Director, Chief of Staff, and Chief of QM. We also 

interviewed QM personnel and several other service chiefs. 

We evaluated plans, policies, and other relevant documents. 

The QM program was generally effective in providing 

oversight of the system’s quality of care. Appropriate review 

structures were in place for the 15 program activities 

reviewed. We made no recommendations. 

Staffing The purpose of this review was to evaluate whether VHA 

facilities had developed comprehensive staffing guidelines 

and whether the guidelines had been met. We found that 

the system had developed staffing guidelines for nurses, and 

we found them to be adequate. 

The system uses hours per patient day (HPPD) as the 

primary staffing methodology. We reviewed staffing for four 

inpatient units for 12 total shifts. We found that guidelines 

for nurse staffing were generally met in all areas reviewed 

and that specific actions had been taken to ensure safe 

patient care. Overall, we found that according to the HPPD 

model, the system had adequate nursing staff. We made no 

recommendations. 

Survey of 

Healthcare 

Experiences of 

Patients 

The purpose of this review was to assess the extent that 

VHA facilities use quarterly survey results of patients’ health 

care experiences with the VHA system to improve patient 

care, treatment, and services. The Performance Analysis 

Center for Excellence of the Office of Quality and 

Performance within VHA is the analytical, methodological, 

and reporting staff for SHEP. VHA set performance 

measure (PM) target results for patients reporting overall 

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

inpatients and 77 percents for outpatients. Facilities are 

expected to address areas that fall below target scores. 

Figures 1 and 2 on the next page show the system’s SHEP 

PM results for inpatients and outpatients, respectively. 

VA Office of Inspector General 11 
Combined Assessment Program Review of the Northern Arizona VA Health Care System, Prescott, AZ 

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

NORTHERN ARIZONA VA HEALTH CARE 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

NORTHERN ARIZONA VA HEALTH CARE SYSTEM

OUTPATIENT OVERALL QUALITY

BY QUARTER

Figure 2:

Meets 

Target

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

VA Office of Inspector General 13 

The system had exceeded the established targets for both 

inpatient and outpatient scores in 7 of the last 8 quarters of 

available data. We made no recommendations. 
Combined Assessment Program Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 14 

Department of 

Veterans Affairs Memorandum 

Date: December 22, 2008 

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

Subject: Combined Assessment Program Review of the Northern 

Arizona VA Health Care System, Prescott, AZ 

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

Director, Management Review Service (10B5) 

I concur with the attached facility draft responses to the recommendations 

for improvement contained in the Combined Assessment Program review 

at the Northern Arizona VA Health Care System. If you have any 

questions or concerns, please contact Joan Funckes, Executive Assistant 

to the Network Director, VISN 18, at 602-222-2699. 
Combined Assessment Program Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Appendix B 

System Director Comments 

VA Office of Inspector General 15 

Department of 

Veterans Affairs Memorandum 

Date: December 12, 2008 

From: Director, Northern Arizona VA Health Care System (649/00) 

Subject: Combined Assessment Program Review of the Northern 

Arizona VA Health Care System, Prescott, AZ 

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

Thank you for allowing us the opportunity to review and respond to the 

subject report. 

The following are our plans of action designed to correct those areas for 

which recommendations were provided. 

Susan A. Angell, MSW, Ph.D. 
Combined Assessment Program Review of the Northern Arizona VA Health Care System, Prescott, AZ 

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 local policy to specify an appropriate 

timeframe for documentation of pain medication effectiveness. 

Concur 

Target Date: December 1, 2008 (complete) 

HCSM 118-NE-11 has been revised to specify that pain medication 

effectiveness must be evaluated within one hour for medications given 

orally, and 30 minutes for medications given intravenously. All pain 

medication effectiveness will be documented by the end of the shift in 

which the medication is administered. 

Recommendation 2. We recommended that the VISN Director ensure 

that the System Director requires clinicians to consistently document pain 

medication effectiveness in a timely manner. 

Concur 

Target Date: December 12, 2008 (complete) 

Process established and in place: (1) All licensed practitioners who 

administer pain medication are responsible to document administered 

pain medication and the effectiveness of that medication in BCMA in a 

timely manner appropriate to that medication and the condition of the 

patient. All licensed practitioners who administer medications run a PRN 

medication effectiveness report in BCMA at the end of their shift and 

document effectiveness of administered medications. (2) Effective 

December 1, 2008, a daily PRN medication effectiveness report will be 

monitored by the NM of each unit, or their designee. (3) Effective 

Jan. 5, 2009, each unit will report a monthly monitor (for the previous 

month) to Clinical Inpatient Service Line Managers for their respective 

units. Compliance requirement will be 100%. 

VA Office of Inspector General 16 
Combined Assessment Program Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Recommendation 3. We recommended that the VISN Director ensure 

that the System Director requires that items in medication refrigerators are 

labeled. 

Concur 

Target Date: December 12, 2008 (complete) 

The issue identified during survey was resolved immediately while 

surveyors were present. A process has been established that all items 

placed in the medication refrigerator by non-Pharmacy staff will be labeled 

with a patient label with full patient identification information. 

Recommendation 4. We recommended that the VISN Director ensure 

that the System Director requires that the ISO participate in EOC rounds. 

Concur 

Target Date: October 29, 2008 (complete) 

The previous NAVAHCS process involved ISO and Privacy Officer 

performing weekly rounds. This process allowed for increased 

effectiveness during the rounds, significantly increased frequency of 

rounds, and decreased disruption to the area being visited. Although it 

appears redundant, based on the direction of the IG/CAP Surveyor, the 

ISO has joined the EOC rounds and continues the rounds described 

above. The findings from the expanded rounds have been incorporated 

into the Sterling Readiness Round report. 

Recommendation 5. We recommended that the VISN Director ensure 

that the System Director requires that suicide prevention posters and 

brochures are displayed in highly visible areas throughout the system. 

Concur 

Target Date: October 15, 2008 (complete) 

At the time of the IG/CAP Survey, suicide prevention posters were present 

in the three most highly visible areas for veterans (Primary Care, Mental 

Health, and the Canteen). The IG/CAP Surveyor requested a specific 

poster be displayed. The poster was obtained, and an additional 

30 posters were placed throughout the facility while the surveyor was 

present. 

Recommendation 6. We recommended that the VISN Director ensure 

that the System Director requires that storage areas are maintained 

properly and that sharp instruments are secured. 

VA Office of Inspector General 17 
Combined Assessment Program Review of the Northern Arizona VA Health Care System, Prescott, AZ 

VA Office of Inspector General 18 

Concur 

Target Date: October 23, 2008 (complete)

A centralized clinical equipment storage area has been established. SPD 

Staff perform daily rounds each evening to check clean storage areas 

throughout the facility for additional equipment that has accumulated 

throughout the day. Any clean clinical equipment stored in the clinical 

areas above the established thresholds is removed and stored in the 

centralized storage area. SPD staff is available by cell phone and will 

deliver requested clinical equipment from the centralized storage area to 

the clinical areas. Every clinical area throughout the facility will maintain 

treatment carts locked and sharps secured at all times that carts are not 

under the immediate supervision of facility staff. Staff assigned to provide 

treatment to patients will assume primary responsibility to maintain 

treatment cart security. Nursing Managers will perform random weekly 

cart/sharps security checks. 

Recommendation 7. We recommended that the VISN Director ensure 

that the System Director requires staff to conduct more frequent ED EOC 

rounds and address any deficiencies identified. 

Concur 

Target Date: October 23, 2008 (complete) 

A centralized clinical equipment storage area has been established. SPD 

Staff perform daily rounds each evening to check clean storage areas 

throughout the facility for additional equipment that has accumulated 

throughout the day. Any clean clinical equipment stored in the clinical 

areas above the established thresholds is removed and stored in the 

centralized storage area. SPD staff is available by cell phone and will 

deliver requested clinical equipment from the centralized storage area to 

the clinical areas. The Emergency Department Nurse Manager has 

instituted daily EOC rounds in the Emergency Department to identify and 

resolve issues immediately. 
Combined Assessment Program Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Appendix C 

VA Office of Inspector General 19 

OIG Contact and Staff Acknowledgments 

Contact Linda DeLong, Director 

Dallas Office of Healthcare Inspections 

(214) 253-3331 

Contributors Karen Moore, Team Leader 

Shirley Carlile 

Wilma Reyes 

Marilyn Walls 

Rich Cady, Office of Investigations 
Combined Assessment Program Review of the Northern Arizona VA Health Care System, Prescott, AZ 

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 Southwest Health Care Network (10N18) 

Director, Northern Arizona VA Health Care System (649/00) 

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: Jeff Flake, Trent Franks, Gabrielle Giffords, 

Raul Grijalva, Ann Kirkpatrick, Harry E. Mitchell, Ed Pastor, John Shadegg 

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