Department of Veterans Affairs 

Office of Inspector General 

Combined Assessment Program 

Review of the 

Tuscaloosa VA Medical Center 

Tuscaloosa, Alabama 

Report No. 07-00157-97 March 14, 2007

VA Office of Inspector General 

Washington, DC 20420 
Office of Inspector General 

Combined Assessment Program Reviews 

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 Tuscaloosa VA Medical Center, Tuscaloosa, Alabama 

Contents 

Page 

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

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

Facility Profile ................................................................................................................. 1

Objectives and Scope of the Combined Assessment Program Review........................... 1

Results of Review.................................................................................................3 

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

Opportunities for Improvement ....................................................................................... 4

Environment of Care .................................................................................................... 4

Breast Cancer Management ......................................................................................... 6

Quality Management Program ..................................................................................... 8 

Other Observations........................................................................................................ 10 

Survey of Healthcare Experiences of Patients ........................................................... 10 

Diabetes and Atypical Antipsychotic Medications.................................................... 11

Appendixes 

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

B. Facility Director Comments..................................................................................... 14

C. OIG Contact and Staff Acknowledgments............................................................... 18

D. Report Distribution .................................................................................................. 19

VA Office of Inspector General 
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama 

Executive Summary 

Introduction 

During the week of November 13, 2006, the Office of Inspector General (OIG) 

conducted a Combined Assessment Program (CAP) review of the Tuscaloosa VA 

Medical Center (referred to as the facility or VAMC). The purpose of the review was to 

evaluate selected facility operations, focusing on quality management (QM) and selected 

areas of patient care. The facility is under the jurisdiction of Veterans Integrated Service 

Network (VISN) 7. 

Results of Review 

This CAP review focused on five health care areas. The facility complied with selected 

standards in the following two areas: 

• Survey of Healthcare Experiences of Patients (SHEP). 

• Diabetes and Atypical Antipsychotic Medications. 

We identified the following organizational strengths: 

• Alabama State Quality Awards. 

• Falls and Restraint Reduction. 

• Hypertension Management. 

We made recommendations in three of the five activities reviewed. For the activities of 

environment of care (EOC), breast cancer management, and the QM Program, the facility 

needed to take action as outlined below and on the next page. 

Environment of Care 

• Ensure all facility fire extinguishers are inspected monthly in accordance with the Life 

Safety Code. 

• Ensure that EOC deficiencies are properly tracked and that data is analyzed, trended, 

and reported to the EOC Committee monthly. 

• Ensure that Facility Management Service (FMS) develops a plan to ensure that the 

facility is properly maintained. 

• Ensure the facility safety manager develops a process to ensure that all construction 

projects are reviewed for potential Interim Life Safety Measures (ILSM) impact, 

action plans are developed, and all reviews are reported to the Construction Safety 

Committee for review by the governing body. 

VA Office of Inspector General i 
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama 

Breast Cancer Management 

• Ensure all biopsy results are communicated to patients. 

• Ensure a Tumor Registry Program is implemented at the facility. 

• Ensure that a tracking mechanism is implemented to follow patients through the 

continuum of care. 

Quality Management Program 

• Implement immediate investigations for all safety assessment code (SAC) 3 adverse 

events and complete individual root cause analyses (RCAs) within 45 days. 

• Document peer reviews at the Chief of Staff level or by the Peer Review Committee 

for all deaths that meet the screening guidelines. 

• Ensure that the physician advisor receives appropriate training for the Utilization 

Management (UM) Program. 

This report was prepared under the direction of Ms. Marisa Casado, Director, 

St. Petersburg Office of Healthcare Inspections. 

Comments 

The VISN and Facility Directors agreed with the CAP review findings and 

recommendations and provided acceptable improvement plans. (See Appendixes A 

and B, pages 12–17, for the full text of the Directors’ comments.) We will follow up on 

the planned actions until they are completed. 

 (original signed by:)

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General ii 
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama 

Introduction 

Facility Profile 

Organization. The Tuscaloosa VA Medical Center is located in Tuscaloosa, Alabama, 

and provides a broad range of inpatient and outpatient health care services. There are no 

current or planned community based outpatient clinics. The facility is part of VISN 7 and 

serves a veteran population that includes 12 counties in western Alabama. 

Programs. The facility provides primary care, mental health, geriatric, and rehabilitation 

services and provides access to secondary and tertiary care services. The facility operates 

146 hospital beds and 198 nursing home beds.

Affiliations and Research. The facility has an active affiliation with the University of 

Alabama School of Medicine. Over 200 university residents, interns, and students are 

trained at the facility each year. There are nursing student affiliations with the University 

of Alabama and the University of Alabama at Birmingham. The facility also has 

affiliations with colleges and universities for schools of health care administration, 

business administration, dietetics, occupational therapy, physical therapy, speechlanguage pathology, telecommunication and film, advertising and public relations, and 

office administration. 

In fiscal year (FY) 2006, the facility’s research program had an estimated 44 projects and 

a budget of $805,907 ($301,304 in VA funding and $504,603 in non-VA funding). 

Important areas of research include the treatment of post-traumatic stress disorder 

(PTSD), depression, bipolar disorder, generalized anxiety disorder in persons over age 

60, agitation in patients with dementia, vocational rehabilitation for patients with PTSD, 

palliative care, bereavement, and hospice care. 

Resources. In FY 2006, medical care expenditures totaled approximately $85 million. 

FY 2006 staffing totaled 827.8 full-time employees (FTE), including 27.4 physician and 

297 nurse FTE. 

Workload. In FY 2006, the facility treated 14,656 unique patients. The facility provided 

45,475 inpatient days of care in the hospital and 50,737 inpatient days of care in the 

Nursing Home Care Unit (NHCU). The inpatient care workload totaled 734 discharges, 

with 640 hospital and 94 nursing home discharges, respectively. The average daily 

census, including nursing home patients, was 287, with 136 hospital and 151 nursing 

home patients, respectively. The outpatient workload was 175,327 visits. 

Objectives and Scope of the Combined Assessment Program Review 

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 this 

VA Office of Inspector General 1 
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama 

CAP review were to conduct recurring evaluations of selected health care facility 

operations, focusing on QM, the facility’s EOC, and selected areas of patient care. 

Scope. We reviewed selected clinical activities to evaluate the effectiveness of QM and 

patient care administration. We also conducted an inspection of the facility’s EOC. QM 

is the process of monitoring the quality of patient care to identify and correct harmful and 

potentially harmful practices and conditions. Patient care administration is the process of 

planning and delivering patient care. EOC is the cleanliness and condition of the 

facility’s patient care areas, the condition of equipment, adherence to clinical standards 

for infection control and patient safety, and compliance with patient data and medicine 

security requirements. 

In performing the review, we inspected work areas; interviewed managers and 

employees; and reviewed clinical and administrative records. This review covered the 

following activities: 

Breast Cancer Management 

Diabetes and Atypical Antipsychotic 

Medications 

EOC 

QM Program 

SHEP 

The review covered facility operations for FYs 2005, 2006, and 2007 through 

November 13 and was done in accordance with OIG standard operating procedures for 

CAP reviews. 

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. We also noted several organizational strengths of the facility during the 

course of the review, and we have included a brief description of these in this report. 

VA Office of Inspector General 2 
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama 

Results of Review 

Organizational Strengths 

We identified the following organizational strengths. 

Alabama State Quality Awards. The facility has been the recipient of two consecutive 

Alabama State Quality Awards that recognized the facility’s QM improvement efforts. 

Specifically: 

• The facility received Alabama State’s highest and most prestigious award for 

Healthcare Quality in 2005—the Quality Award in Healthcare in 2005 (Level III). 

This was the only award to a VA facility in Alabama. The award cited the facility’s 

use of seven Baldrige Boards to implement Baldrige criteria throughout the facility. 

The facility was also recognized for its work on the transition center for veterans 

returning from Iraq, as well as for the creation of the Hurricane Katrina Response and 

Recovery Center for veterans displaced by Hurricane Katrina. 

• The facility also received the 2006 Alabama Quality Award of Excellence in 

Continuous Productivity and Quality Improvement. The award recognized the facility 

for the development of the Acting to Improve Medical Health Outcomes (AIM-HI). 

The award acknowledged the significant improvements made by the facility in the 

care of mental health patients related to cancer screening and diabetes management. 

Falls and Restraint Reduction. The facility initiated a major safety initiative for FYs 

2002 and 2003 with the goal of reducing falls with major injuries. Actions taken by the 

facility’s team included implementation of the Morse falls scale, acquisition of special 

equipment for falls prevention (low beds, bed/chair alarms, and hip protector pads), and 

education of patient/staff on falls reduction. As a result of the facility’s efforts, a 

reduction in rate of falls with and without injury has been sustained for several years. 

While reducing the injuries related to falls, the facility was able to significantly reduce 

the total number of restraint events over time from 1,240 events in FY 2000 to 6 events in 

FY 2006. 

Hypertension Management. The process action team on hypertension implemented the 

following actions, which led to improved compliance on blood pressure (BP) control: 

(a) conversion to manual BP machines, (b) training and reinforcement of correct BP 

technique, (c) dispensing of home BP devices to patients, (d) development of clinical 

reminders and provider report cards on hypertension, and (e) referrals to a pharmacist for 

difficult to manage patients. As a result of these interventions, the facility improved its 

BP performance measure (PM) results by 43 percent between FYs 1999 and 2006. 

VA Office of Inspector General 3 
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama 

Opportunities for Improvement 

Environment of Care 

Conditions Needing Improvement. VA policy requires that patient care areas be clean, 

sanitary, and maintained to optimize patient safety and infection control. We reviewed 

various facility EOC-related committee minutes for the period March through August 

2006. We inspected all patient care areas and found conditions requiring management 

attention. The facility needs to address life safety and fire safety measures. Also, the 

facility needs to place increased emphasis on the general interior maintenance and 

appearance of the facility. 

Fire Safety Review and Equipment Inspection Documentation. We conducted a review 

of fire safety documentation, as submitted to the facility’s EOC Committee, for the 

period March through August 2006. This review included documentation of fire drills 

and fire safety equipment inspections. 

The NHCU fire extinguishers were delinquent in receiving the required monthly 

inspection. The National Fire Protection Association (NFPA) requires that, “Fire 

extinguishers shall be inspected either manually or by means of an electronic monitoring 

device/system at a minimum of 30-day intervals.”1

 During a visual review of individual 

fire extinguisher inspection cards, we found inspection frequency and dates of completion 

of this inspection during the first week of each month (5th–6th). However, as of the OIG 

inspection (November 13, 2006), the NHCU’s monthly fire extinguisher inspection for 

November had not been completed, and the fire extinguishers were not in compliance 

with the NFPA Life Safety Code. 

EOC Management Program. We found that the facility used an individualized monthly 

tracking report rather than a cumulative tracking system. While a “tour date” field is 

used on the facility’s tracking spreadsheet, no “completed date” field is available for 

comparison against the facility’s “14-day completion” PM, as stated in Medical Center 

Policy (MCP) 001-25, Environment of Care Management Plan. 

Facility policy2

 requires the Chief of FMS to complete tracking of deficiencies observed 

by facility staff during scheduled EOC rounds. No review by the EOC Committee of the 

status of deficiencies (cumulative data, completion rates, and outliers) identified during 

EOC rounds was found in any EOC minutes. 

Lack of reviewable and reliable information inhibits management’s ability to attend to 

and monitor a safe environment for patients, staff, and visitors. The absence of an 

effective EOC deficiency tracking system, which provides timely and accurate data that 

 

1

 NFPA Code 10-7.2.1.2. 

2

 Facility’s MCP 001-25, Environment of Care Management Plan, paragraph IV.4. 

VA Office of Inspector General 4 
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama 

facilitates reviews and corrective action by facility staff and management, may create an 

environment where unsafe conditions remain uncorrected, thus compromising the safety 

of patients, staff, and visitors. 

Maintenance and Repair Activities. A tour of the facility’s NHCU was completed to 

validate the effectiveness of the facility’s EOC rounds system. We documented 30 

examples of maintenance and repair lapses in patient-occupied rooms and direct patient 

support areas. The EOC deficiencies we observed potentially compromised patient safety 

and health and included light fixtures and lens covers with potential to fall, peeling paint 

on the dementia unit, unsafe electrical switches, and exposed wiring.3

 

While we found exterior surfaces of the NHCU exhaust fans to be clean, internal control 

vanes, which are located beyond the exterior surfaces cleaned by housekeeping aids, were 

obstructed due to accumulated dirt and dust. This provides an environment in which 

bacteria, mold, and mildew can develop, which could compromise the health of patients 

and employees. 

Construction Safety Committee Minutes. We reviewed the Construction Safety 

Committee minutes. The facility did not adequately document that they used appropriate 

criteria to assess life safety/fire safety issues related to construction projects. The 

Construction Risk Assessment and Fire Safety criteria of the NFPA 101: Life Safety 

Code4

 should have been discussed, reviewed, and approved by facility management for 

contractor and patient/employee safety issues. We found no evidence of a review using 

these criteria in the EOC Committee minutes or in any other facility management report. 

This is a repeat finding from the facility’s FY 2005 Annual Workplace Evaluation.5

 

Recommended Improvement Action 1. We recommended that the VISN Director 

ensure that the Facility Director takes action to ensure that: (a) all facility fire 

extinguishers are inspected monthly in accordance with the Life Safety Code; (b) EOC 

deficiencies are properly tracked and data is analyzed, trended, and reported to the EOC 

Committee monthly; (c) FMS develops a plan to ensure the facility is properly 

maintained; and (d) the facility safety manager develops a process to ensure that all 

construction projects are reviewed for potential Interim Life Safety Measures (ILSM) 

impact, action plans are developed, and all reviews are reported to the Construction 

Safety Committee for review by the governing body.

 

3

 This is documented in a summary and photographs from our inspection conducted on November 13, 2006. 

4

 Joint Commission on Accreditation of Healthcare Organizations, EC.5.50, “Interim Life Safety Measures,” 2006 

Hospital Accreditation Standards, page 297. 5

 FY-05 Annual Workplace Evaluation (AWE), Tuscaloosa VAMC, Item 2-7-5A, dated 1/29/06. 

VA Office of Inspector General 5 
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama 

Breast Cancer Management 

Conditions Needing Improvement. Not all biopsy results were communicated to the 

patients in accordance with Veteran Health Administration (VHA) Handbook 1104.1.6

 

The facility needed to improve their tracking process to monitor patients through the 

continuum of care and implement a Tumor Registry Program onsite, in accordance with 

VHA Directive 2003-034.7

 

The VHA breast cancer screening PM assesses the percent of patients screened according 

to prescribed timeframes. Three of 4 quarters did not meet the required standard, as 

shown in the chart below. 

Breast Cancer Screening

Tuscaloosa VAMC

84

86 87

83

85 86

100

80

75

72

84

84

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

Qtr 1 Qtr 2 Qtr 3 Qtr 4

Percent

Facility

VISN

National

Better

FY 2005 Performance Measure Scores Fully 

Satisfactory 

Score = 85%

Timely screening, diagnosis, communication, interdisciplinary treatment planning, and 

treatment are essential to early detection, appropriate management, and optimal patient 

outcomes. VHA mammography standards require documentation of normal findings to 

be included in the medical record within 30 days of the procedure. According to VHA 

Directive 2003-034, communication of suspicious or abnormal results to the ordering 

provider is required within 3 working days. Communication can be by telephone contact 

between the mammography procedure site and the ordering provider. If this is the 

method adopted, entry into the electronic patient record is required. Timely results need 

 

6

 VHA Handbook 1104.1, Mammography Standards, August 6, 2003. 7

 VHA Directive 2003-034, National Cancer Strategy, June 29, 2003. 

VA Office of Inspector General 6 
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama 

to be available and accessible to guide patient care and treatment. We assessed these 

items in a review of three patients diagnosed with either breast cancer or an abnormal 

mammography during FYs 2004 and 2005. 

We found that three of three patients (100 percent) were appropriately screened for breast 

cancer. Mammography results were reported to patients within 30 working days, patients 

were appropriately notified of their diagnoses, and patients received timely biopsy 

procedures. Only two patients required consultations for oncology, surgery, and/or radiation 

therapy; the consultations were done timely. However, we determined that: (a) not all biopsy 

results were communicated to the patients or documented in medical record, (b) the facility 

did not have a Tumor Registry onsite as required by the directive, and (c) a tracking process 

to monitor patients through the continuum of care was not implemented. 

Patients 

appropriately 

screened 

Mammography 

results reported 

to patient 

within 30 days 

Patients 

appropriately 

notified of their 

diagnoses 

Patients 

received timely 

consultations 

Patients 

received 

timely biopsy 

procedure 

3/3 3/3 3/3 2/2 3/3 

The facility’s mammographies and biopsies are performed at community affiliates on a feefor-service basis. There was a lack of communication and documentation between the feebasis affiliates and the facility, which precluded verification that biopsy results were reported 

to the patient as required by VHA Handbook 1104.1. 

VHA Directive 2003-034 requires every facility to have a Tumor Registry in place to 

monitor patients diagnosed with cancer. We were told that the facility does not have a 

Tumor Registry or a sharing agreement with another local facility. Facility staff reported 

that the facility is coordinating with local off-site affiliates and other VA medical centers to 

develop a sharing agreement for Tumor Registry services. 

The facility had a tracking system to monitor breast cancer patients once diagnosed, but the 

facility did not monitor patients through the full continuum of care. Staff reported that the 

facility was in the process of reconstructing the tracking process. Another FTE had been 

added to the program to assist with the reconstruction of the tracking system. However, the 

FTE position was vacant at the time of our site visit. 

Recommended Improvement Action 2. We recommended that the VISN Director 

ensure that the Facility Director takes action to ensure that: (a) all biopsy results are 

communicated to patients, (b) a Tumor Registry Program is implemented at the facility, 

and (c) a tracking mechanism is implemented to follow the patients through the 

continuum of care. 

VA Office of Inspector General 7 
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama 

Quality Management Program 

Conditions Needing Improvement. The purpose of this review was to evaluate whether 

the facility’s QM Program provided comprehensive oversight of quality of care and 

whether senior managers actively supported the program’s activities. We interviewed the 

facility Director, Chief of Staff, Chief Nurse Executive, and QM personnel, and we 

evaluated plans, policies, and other relevant documents. The facility’s QM/Performance 

Improvement Program was comprehensive and generally effective; however, we found 

three areas for performance improvement. 

Patient Safety. VHA Handbook 1050.18 defines requirements for facility patient safety 

programs to effectively manage adverse events. We reviewed major components of the 

program and found areas needing attention. A critical part of the Patient Safety Program 

is properly executing the individual RCA process for adverse events. 

We reviewed a total of five RCAs, which by VHA guidelines require investigation and 

completion within 45 days. We found one RCA with an SAC score of 3 (indicating a 

major injury from a fall that requires surgical repair and extended days of acute hospital 

care). We found that the RCA team was not chartered until 78 days after the facility 

became aware of the event, and the team did not complete the investigation until 157 

days had transpired. In the four additional RCAs, we found that none of the four were 

completed within 45 days; all four remained in progress at the time of our review. 

Peer Review. VHA Directive 2004-0549 delineates an important process of mortality 

assessment screening to identify cases that require peer review. We reviewed 1st quarter 

FY 2006 mortality data and found one case that met screening guidelines for peer review. 

Although QM staff told us that this case was discussed with and reviewed by the Chief of 

Staff, no documentation of his review was available. If the decision is made not to 

proceed with a formal review by the Peer Review Committee, VHA Directive 2004-054 

requires documentation of that decision. We found no such documentation. 

Utilization Management. VHA Directive 2005-04010 defines program components that 

must be in place to perform UM functions. We found that most areas were in compliance 

with the intent of VHA Directive 2005-040. However, the Chief of Staff did not appoint 

a Physician Advisor until November 14, 2006, and no documentation of the Physician 

Advisor’s required training11 could be produced. 

Recommended Improvement Action 3. We recommended that the VISN Director 

ensure that the Facility Director takes action to (a) implement immediate investigations 

 

8

 VHA Handbook 1050.1, VHA National Patient Safety Improvement Handbook, January 30, 2002. 9

 VHA Directive 2004-054, Peer Review for Quality Management, September 29, 2004. 10 VHA Directive 2005-040, Utilization Management Policy, September 22, 2005. 11 The Physician Advisor must have training for physicians in Utilization Management, which is available from a 

variety of sources. 

VA Office of Inspector General 8 
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama 

for all SAC 3 adverse events and complete individual RCAs within 45 days, (b) 

document peer reviews at the Chief of Staff level or by the Peer Review Committee for 

all deaths that meet the screening guidelines, and (c) ensure that the Physician Advisor 

receives appropriate training for the UM Program. 

VA Office of Inspector General 9 
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama 

Other Observations 

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 analyses, 

interpretations, and delivery of the survey data for making administrative and clinical 

decisions for improving the quality of care delivered to patients. VHA’s Executive 

Career Field Performance Plan states that in FY 2006, at least 77 percent of ambulatory 

care patients and 76 percent of inpatients discharged during a specified date range will 

report their experiences as Very Good or Excellent. The following graphs show the 

facility’s performance in relation to national and VISN performance for inpatients and 

outpatients. Medical centers are expected to address areas in which they are 

underperforming. In the following two charts, note that “+” indicates results that are 

significantly better than the national average and “-” indicates scores that are significantly 

worse than the national average. 

Inpatient SHEP Results – Q3 and Q4 FY 2005 

INPATIENT – Q3 and Q4 

FY 2005 

Access 

Coordination 

of Care 

Courtesy 

Education & 

Information 

Emotional 

Support 

Family 

Involvement 

Physical 

Comfort 

Preferences 

Transition 

National 80.73 78.27 89.40 67.36 65.08 75.37 83.35 73.98 69.52 

VISN 80.70 78.70 89.30 68.4+ 66.00 74.90 81.5- 74.30 69.30 

Tuscaloosa 80.50 77.80 81.9- 64- 57.7- 59.9- 78.1- 64.8- 60.7- 

Out tient SHEP Res ts – Q3 FY 2 6 pa ul 00

Outpatient – Q3 

FY 2006 

Access 

Coordination 

of Care 

Courtesy 

Education & 

Information 

Emotional 

Support 

Overall 

Coordination 

Pharmacy 

Mailed 

Pharmacy 

Pick-up 

Transition 

Specialist 

Care 

Visit 

Coordination 

National 80.9 77 94.6 72 83 75.1 81.1 64.4 81.3 80.5 84.1 

VISN 75.5 76 92.1 69.7 79.9 74.6 82.1 58.1 79.7 79.9 80.9 

Tuscaloosa 81.5 84 96.9 74.4 81.9 75.7 75.3 * 81 82.9 89.4 

* signifies fewer than 30 respondents

The facility has a Customer Service Subcouncil that meets monthly and a designated 

Customer Service Coordinator. SHEP results were analyzed and action plans developed 

to address areas needing improvement. Ongoing facility initiatives to maintain and 

improve current levels of customer service include a “Service Recovery” program that 

permits timely resolution of complaints and a “QuickCard” survey in the outpatient 

clinics that provides daily customer feedback for service in the facility. 

VA Office of Inspector General 10 
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama 

Diabetes and Atypical Antipsychotic Medications 

The purpose of this review was to determine the effectiveness of diabetes screening, 

monitoring, and treatment of mental health patients receiving atypical antipsychotic 

medications (medications that cause fewer neurological side effects but increase the 

patient’s risk for the development of diabetes). 

VHA clinical practice guidelines for the management of diabetes suggest that diabetic 

patients’ hemoglobin A1c (HbA1c), which reflects the average blood glucose level over a 

period of time, should be less than 9 percent to avoid symptoms of hyperglycemia; BP 

should be less than or equal to 140/90 millimeters of mercury (mmHg); and low density 

lipoprotein cholesterol (LDL-C) should be less than 120 milligrams per deciliter (mg/dL). 

To receive a fully satisfactory rating for these diabetes PMs, the facility must achieve the 

following scores: 

• HbA1c greater than 9 percent – 15 percent (lower percent is better) 

• BP less than or equal to 140/90mmHg – 72 percent (higher percent is better) 

• Cholesterol (LDL-C) less than 120mg/dL – 75 percent (higher percent is better) 

We reviewed the facility’s four diabetes-related PMs for FY 2005. We found that the 

facility met 31 percent (4/13) of VHA FY 2005 quarterly PM goals related to diabetes for 

which data was reported. Specifically, we found: 

• HbA1c greater than 9 percent – The facility did not meet any PM thresholds for FY 

2005. 

• BP less than or equal to 140/90mmHg – The facility met or exceeded PM thresholds 

for quarter (Q)1, Q3, and Q4. 

• BP greater than or equal to 160/100mmHg – The facility did not meet any PM 

threshold for FY 2005. In fact, no data was reflected for Q1, Q3, or Q4 for this PM. 

• LDL-C less than 120mg/dL – The facility met or exceeded the PM threshold only for 

Q1. 

The facility had a proactive outcome-focused approach to address improvement. The 

facility’s corrective efforts for the diabetes-related PMs include the following: 

• The facility developed an internal PM database to more effectively monitor diabetesrelated measures. The database facilitated weekly reviews by the facility rather than 

waiting for quarterly results. This allowed the facility to respond to PM shortcomings 

and adjust corrective actions to meet PM thresholds. 

• The facility analyzed patient workload to identify any patient population that was not 

being effectively serviced or monitored. The analysis identified a single patient 

VA Office of Inspector General 11 
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama 

population and allowed the facility to adjust providers and treatment protocols to 

more effectively meet patient care needs and improve PM outcomes. 

• The facility continuously monitored progress monthly through two committees—the 

Process Management Committee and the AIM-HI Committee. Additionally, facility 

managers meet weekly to review data and make any adjustments to ensure continuous 

improvement. 

We reviewed medical records for a sample of 13 randomly selected patients who were on 

one or more atypical antipsychotic medications for at least 90 days in FY 2005. None of 

the patients reviewed had a diagnosis of diabetes. Nine patients had clinical indicators 

indicative of a predisposition to diabetes; they received prevention counseling. 

Diabetic patients 

with HbA1c 

greater than 9 

percent 

Diabetic patients 

with BP less than 

or equal to 

140/90mm/Hg 

Diabetic patients 

with LDL-C less 

than 120mg/dL 

Non-diabetic 

patients 

appropriately 

screened 

Non-diabetic 

patients who 

received diabetes 

prevention 

counseling 

0/0 0/0 0/0 13/13 9/9 

VA Office of Inspector General 12 
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum

Date: December 6, 2006 

From: Acting Director, VA Southeast Network (10N7) 

Subj: Combined Assessment Program Review of the 

Tuscaloosa VA Medical Center 

To: Director, St. Petersburg Office of Healthcare Inspections 

(54SP) 

1. Attached is Tuscaloosa’s response to the Office of 

Inspector General (OIG) Combined Assessment Program 

Review Site Visit during the week of November 13, 2006. I 

have reviewed the CAP recommendations, which have been 

individually addressed. 

2. I understand recommendations (1b) ensure 

documentation of required extinguisher annual safety 

inspections and (1c) quarterly fire drill data is reported to and 

reviewed by the facilities EOC committee, have been dropped 

along with the findings. 

3. I concur with the comments and actions taken by the 

Medical Center Director as outlined in the comments and 

implementation plan to improve processes at the Tuscaloosa 

VA Medical Center. 

 (original signed by:)

Thomas A. Cappello, MPH, FACHE 

Attachments 

VA Office of Inspector General 13 
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama

Appendix B 

Tuscaloosa VA Medical Center 

Response to the Office of Inspector General Combined 

Assessment Program Review Report 

Comments and Implementation Plan

1. Environment of Care 

Recommended Improvement Action 1. We recommended that the VISN 

Director ensure that the Facility Director takes action to ensure that: (a) all 

facility fire extinguishers are inspected monthly in accordance with the Life 

Safety Code; (b) EOC deficiencies are properly tracked and data is 

analyzed, trended, and reported to the EOC Committee monthly; (c) FMS 

develops a plan to ensure the facility is properly maintained; and (d) the 

facility safety manager documents all ILSM safety reviews and outcomes to 

the Construction Safety Committee. 

Concur with recommended improvement actions 

a. Ensure all facility fire extinguishers are inspected monthly in 

accordance with the Life Safety Code. 

Planned Action: Medical Center will ensure that all fire extinguishers are 

inspected and documented monthly in accordance with the Life Safety 

Code. (Completed: November 2006)

b. EOC deficiencies are properly tracked; data is analyzed, 

trended, and reported to the EOC Committee monthly.

Planned Action: EOC deficiencies shall be tracked and that data analyzed, 

trended, and reported to the EOC Committee monthly. (Target Date: 

December 2006)

c. Ensure that Facility Management Service develops a plan to 

ensure that the facility is properly maintained. 

Planned Action: A process action team will be established to evaluate our 

current maintenance system and make recommendations for a more 

proactive approach. (Target Date: February 2007) Until improved 

processes are in place, the maintenance staff will conduct weekly rounds to 

ensure like items do not reoccur. (Target Date: December 2006)

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Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, AL

d. Ensure the facility safety manager develops a process to ensure 

that all construction projects are reviewed for potential Interim Life 

Safety Measures impact, action plans are developed, and all reviews 

are reported to the Construction Safety Committee for review by the 

governing body. 

Planned Action: Interim Life Safety Measures will be evaluated and 

documented in the Construction Safety Committee minutes. (Target Date: 

December 2006)

2. Breast Cancer 

Recommended Improvement Action 2: We recommended that the VISN 

Director ensure that the facility Director takes action to ensure that: (a) all 

biopsy results are communicated to patients, (b) a Tumor Registry Program 

is implemented at the facility, and (c) a tracking mechanism is implemented 

to follow the patients through the continuum of care. 

Concur with recommended improvement actions

a. Ensure all biopsy results are communicated to patients.

Planned Action: (Target Date: February 2007)

• Oncology Care Coordination Program Implemented November 

2006. Data which is being case managed, tracked, and reported include: 

• Ensuring normal findings are documented in the medical record and 

communicated to patient within 30 days. 

• Ensuring abnormal test results are communicated to the ordering 

provider and documented in the medical record within 3 days. 

• Ensuring abnormal test results are communicated to the patient and 

documented in the medical record within 5 days. 

b. Ensure a Tumor Registry Program is implemented at the 

facility.

Planned Action: A meeting has been scheduled with TVAMC Chief of 

Staff and BVAMC Chief of Staff on December 12, 2006. Also in 

attendance will be the Director of the Office of Care Coordination from 

TVAMC and Primary Care Physician who specializes in Oncology from 

TVAMC. The meeting is to discuss a shared tumor registry between 

BVAMC and TVAMC. (Target Date: December 2006)

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Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, AL

Suspicious Lesion – Screening, Early Detection, Diagnosis, and Tumor

Registry –Consists of time from original abnormal test (suspicious lesion 

identified by physical, radiological, or laboratory evaluation) or positive 

cancer screening test that raises reasonable possibility of cancer, to the 

point of cancer diagnosis or exclusion. During this phase the Suspicious 

Lesion Case Manager serves as a facilitator to ensure timely care is 

provided: 

 Utilizing a standardized process to identify all suspicious lesion 

reports and provide ongoing management of the tumor registry. 

 Ensuring the Primary Care Provider is notified of suspicious lesion 

and a plan of care is implemented in a timely manner. 

 Assisting in coordinating any additional diagnostic testing in a 

timely manner. 

 Ensuring the Primary Care Provider is notified of suspicious lesion 

and a plan of care is implemented in a timely manner. 

 Assisting in coordinating any additional diagnostic testing in a 

timely manner 

 Providing on-going case management until confirmation or 

exclusion of malignancy. 

c. Ensure that a tracking mechanism is implemented to follow the 

patients through the continuum of care. 

Planned Action: The Oncology Care Coordination Program will ensure 

that a tracking mechanism is implemented to follow the patients through 

the continuum of care by focusing on the coordination and management of 

services for patients through all phases of cancer treatment. These elements 

incorporate the eight VHA national strategies for oncology care. (Target 

Date: February 2007)

Prevention and education: The Oncology Case Manager(s) will 

collaborate with patients, health care providers, TVAMC Patient Health 

Education Resource Center, and community vendors to ensure that 

TVAMC patients are well informed about the processes of care required for 

their medical treatment from the identification of a suspicious lesion or 

positive screening test through diagnosis and treatment. 

Treatment – Active Treatment Phase: In addition to the Prevention and 

education, the case manager will continue case management services 

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Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, AL

throughout the active treatment and/or palliative care phases until 

confirmation or exclusion of malignancy. 

3. Quality Management 

Recommended Improvement Action 3: We recommended that the VISN 

Director ensure that the facility Director takes action to (a) implement 

immediate investigations for all SAC 3 adverse events and complete 

individual RCAs within 45 days, (b) document peer reviews at the Chief of 

Staff level or by the Peer Review Committee for all deaths that meet the 

screening guidelines, (c) ensure that the Physician Advisor receives 

appropriate training for the UM Program. 

Concur with recommended improvement actions 

a. Implement immediate investigations for all safety assessment 

code [SAC] 3 adverse events and complete individual Root Cause 

Analyses within 45 days; 

Planned Action: Revise current process to ensure the immediate RCA 

teams are appointed for all safety assessment code [SAC] 3 adverse events 

and complete individual Root Cause Analyses within 45 days. Specifically 

the process for implementing RCAs has been changed to ensure the RCA 

process for [SAC] 3 adverse events is immediate. (Completed 

November 17, 2006.)

b. Document peer reviews at Chief of Staff level and/or Peer 

Review Committee for all deaths that meet the screening guidelines. 

Planned Action: Revise current peer review process to ensure the Chief of 

Staff level or Peer Review Committee reviews all deaths that meet the 

screening guidelines. Specifically the Chief of Staff will sign all cases 

documenting that he has reviewed and concurs with action. (Completed 

November 14, 2006.)

c. Ensure that the Physician Advisor receive appropriate training 

for the UM program. 

Planned Action: The Physician Advisor will attend additional training of 

utilization management and this training will be documented in his 

competency files. This training will incorporate the required InterQual 

criteria for admission and continued stay and be implemented by February 

2007. (Target Date: February 2007)

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Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Marisa Casado, Director 

St. Petersburg Regional Office 

(727) 395-2415 

Acknowledgments Charles Cook, Team Leader 

David Griffith 

Deborah Howard 

Annette Robinson 

Idell Graham 

Elizabeth Bullock 

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Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network (10N7) 

Director, Tuscaloosa VA Medical Center (679/00) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction and Veterans Affairs 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction and Veterans Affairs 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Jeff Sessions and Richard C. Shelby 

U.S. House of Representatives: Artur Davis 

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

VA Office of Inspector General 19