Department of Veterans Affairs 

Office of Inspector General 

Combined Assessment 

Program Review of the 

W.G. (Bill) Hefner VA Medical Center 

Salisbury, North Carolina 

Report No. 06-02245-220 September 25, 2006

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 services are 

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 W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

Contents 

Page 

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

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

Medical Center Profile..................................................................................................... 1

Objectives and Scope of the CAP Review ...................................................................... 1

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

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

Opportunities for Improvement ..........................................................................3

Contract Nursing Home Program................................................................................. 3 

Quality Management.................................................................................................... 6

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

Other Focused Review Results...........................................................................9

Diabetes and Atypical Antipsychotic Medications...................................................... 9

Breast Cancer Management ......................................................................................... 9

Patient Satisfaction..................................................................................................... 10 

Appendixes .........................................................................................................11

A. VISN Director’s Comments...................................................................................... 12

B. Medical Center Director’s Comments ...................................................................... 13

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

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

VA Office of Inspector General 
Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

Executive Summary 

Introduction 

During the week of June 19–23, 2006, the Office of the Inspector General (OIG)

conducted a Combined Assessment Program (CAP) review of the W.G. (Bill) Hefner 

Medical Center (the medical center), Salisbury, North Carolina. The purpose of the 

review was to evaluate selected operations, focusing on patient care administration and 

quality management (QM). During the review, we provided fraud and integrity 

awareness training to 410 employees. 

Results of Review 

The CAP review focused on six areas. The medical center complied with selected

standards in the following three areas: 

• Diabetes and Atypical Antipsychotic Medication 

• Breast Cancer Management 

• Patient Satisfaction 

We identified conditions in the Contract Nursing Home (CNH) Program, QM, and 

Environment of Care that needed management attention. The following 

recommendations were made: 

• Improve oversight of the CNH Program. 

• Strengthen selected aspects of the QM program. 

• Improve Food and Nutrition Service kitchen ceiling and air diffuser cleanliness. 

VISN and Medical Center Directors’ Comments 

The VISN and Medical Center Directors concurred with the CAP review findings and 

recommendations and provided acceptable improvement plans. (See pages 12–18 for the 

full text of the Directors’ comments.) We will follow up on planned improvement 

actions. 

 (original signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General i 
Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

Introduction 

Medical Center Profile 

Organization. The medical center provides a broad range of inpatient and outpatient 

health care services. Outpatient care is provided at two community based clinics 

(CBOCs) located in Charlotte and Winston-Salem. The medical center is part of 

Veterans Integrated Service Network (VISN) 6 and serves a veteran population of about

229,600 in a primary service area that includes 23 counties in the Piedmont region of 

North Carolina. 

Programs. The medical center provides medical, surgical, mental health, geriatric, and 

rehabilitation services. The medical center has 159 hospital beds and 270 long-term care

beds and operates several regional referral and treatment programs, including PostTraumatic Stress Disorder, a Substance Abuse Residential Rehabilitation Treatment 

Program, and Psychiatric Intensive Care. 

Affiliations and Research. The medical center has 13 active research projects with 

almost $300,000 in funding and collaborates on research with Wake Forest University,

the affiliated medical school program. Major areas of research include VA rehabilitation, 

mobility devices for veterans with visual impairments, and post-deployment mental 

health issues of returning Operation Enduring Freedom and Operation Iraqi Freedom 

veterans. 

Resources. In fiscal year (FY) 2005, medical care expenditures totaled $187 million. 

The FY 2006 medical care budget is $200 million. FY 2005 staffing totaled 1,440 fulltime equivalent employees (FTE), including 110 physician and 420 nursing FTE. 

Workload. In FY 2005, the medical center treated 58,255 unique patients. The medical 

center provided 33,705 inpatient days of care in the hospital and 54,758 inpatient days of

care in the Nursing Home Care Unit (NHCU). The inpatient care workload totaled 2,973 

discharges, and the average daily census was 265.8, including nursing home patients. 

The outpatient workload was 361,622 visits. 

Objectives and Scope of the CAP 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 the 

CAP review are to: 

• Conduct recurring evaluations of selected health care facilities focusing on patient 

care and QM. 

VA Office of Inspector General 1 
Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

• 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 QM and patient care administration. QM is the process of monitoring 

the quality of care to identify and correct harmful or potentially harmful practices or 

conditions. Patient care administration is the process of planning and delivering patient 

care. In addition, we conducted follow-up on selected aspects of our previous CAP

review (Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical 

Center, Salisbury, North Carolina, Report No. 03-02420-06, October 10, 2003).

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

and patients; and reviewed clinical and administrative records. The review covered 

selected aspects of the following programs and activities: 

Breast Cancer Management Environment of Care 

Contract Nursing Home Program Patient Satisfaction 

Diabetes and Atypical Antipsychotic 

 Medications 

Quality Management 

The review covered medical center operations for FY 2005 and FY 2006 through 

June 23, 2006, and was completed 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. 

VA Office of Inspector General 2 
Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

Results of Review 

Organizational Strengths 

New Technology Improved Patient Care 

Medical center management implemented innovative approaches to providing quality 

patient care by utilizing state of the art technology. Examples include: (a) the purchase of 

instrumentation to measure troponin

1

 at the point of care in the Evaluation Center, 

allowing for timely evaluation of patients with acute coronary syndrome (ACS); and (b) 

the implementation of the CareTracker system, which collects charting data through 

touch-screen devices that encourage NHCU staff to enter all the care they provide. Data 

reflected improvement in patient outcomes and related performance measures since 

implementation of these systems. 

The medical center’s score for the provision of troponin laboratory results within 

60 minutes of order time in January 2005 was 50 percent compliance. The Performance 

Measure target is 89 percent compliance. After implementing the point of care testing, 

the medical center achieved and maintained 100 percent compliance on this important 

measure of ACS care. Medical center managers attribute improvement in a Performance 

Measure related to toileting plans for incontinent patients to implementation of the 

CareTracker system. As a result of its success at this medical center, VISN 6 has

contracted to purchase the CareTracker system for all long term care units in the VISN. 

Opportunities for Improvement 

Contract Nursing Home Program – Oversight Needed Improvement 

We reviewed the CNH Program to assess compliance with national policies regarding 

program management, the review process for contract renewal, and the monitoring of 

patients. We evaluated whether there were effective processes in place to more closely 

monitor the contract nursing facilities where deficiencies had been identified. 

The medical center currently has 17 veterans in 11 contract nursing facilities. We

selected five contract nursing facilities for review and visited two of them. We 

interviewed the administrators at these two sites. We conducted 10 patient record 

reviews and interviewed 4 patients and/or family members. Although VA CNH 

inspection teams conducted annual inspections, and the contract nursing facility 

 1 Troponin is a protein complex which is used as a diagnostic marker for various heart disorders. 

VA Office of Inspector General 3 
Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

administrators felt the VA CNH Program coordinator was accessible and responsive, we 

found several conditions requiring management attention. 

Conditions Needing Improvement. Oversight of the CNH Program needed 

improvement to ensure that veterans in these facilities received quality care in safe 

environments. We identified problems in the following Program components: 

Ongoing Monitoring and Follow-Up Visits. The VA CNH Program nurse did not 

perform regular visits to contract nursing facilities to monitor patients. Veterans Health 

Administration (VHA) Handbook 1143.2 requires that a social worker or registered nurse 

visit every VA patient under contract in a contract nursing facility at least every 30 days; 

nurses are expected to visit, at a minimum, every quarter. Although the VA CNH 

Program coordinator, a social worker, visited the patients monthly, we found no evidence 

that the VA CNH nurse regularly visited the patients to monitor their medical conditions. 

Most of the 10 patients in our sample had multiple medical conditions including 

emphysema, stroke, dysphagia, diabetes, Parkinson’s Disease, multiple sclerosis, and 

chronic renal failure. 

On rare occasions, the nurse would visit a patient in response to a request from the 

contract nursing facility, or when the contract nursing facility reported a sentinel event. 

She did not conduct follow-up visits to the 10 patients in our sample between October 

2003 and June 2006. She told us that she did not have time to make these visits, but 

reviewed information sent to her by the contract nursing facility staff on each patient. 

Her infrequent progress note entries indicated that all patients were stable; however, we 

found progress notes on several patients reflecting recent hospital admissions, significant

weight loss, or other clinical changes in condition. She signed one such note on a patient

12 days after his death. 

The VA CNH population is aging, frail, and often mentally and/or physically disabled. A 

registered nurse needs to monitor the medical conditions of these veterans to assure 

appropriate care in the contract nursing facility and to intervene, when possible, to 

prevent or minimize hospitalizations. 

Oversight of Substandard Nursing Facilities. We found no evidence that VA CNH

Program staff increased monitoring of veterans in substandard contract nursing facilities. 

Four of the 11 contract nursing facilities were currently on the state nursing home “watch 

list.” This list provides consumers with information about nursing homes found to be

deficient during their most recent state inspection. The VA CNH Program utilized the 

“exclusion review” form as part of their initial and annual review. Contract nursing 

facilities are to be excluded from the program when they exceed the allowable scope, 

severity, or number of deficiencies, and do not meet minimum threshold standards for 

quality of care. Several options are available to VA CNH Program managers when a 

facility does not meet these thresholds, such as termination of the contract, suspension of

admissions, more frequent inspections, and increased patient monitoring. 

VA Office of Inspector General 4 
Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

We found that VA CNH Program managers rarely exercised any of these options. All 

five of the facilities we reviewed did not meet the minimum threshold standards for 

quality of care, yet all of their contracts were renewed. In some cases, we found that a 

waiver of the exclusion was requested, but poorly justified. In these cases, we found 

increased monitoring recommended at the time of contract renewal, but no evidence that 

it occurred. Increased monitoring of substandard nursing facilities to ensure acceptable 

standards of care is essential to safeguard the well-being of the veteran residents. 

Compliance with Policy. Managers had not established a CNH Oversight Committee, 

and the VA CNH Program coordinator did not meet with local Ombudsmen as required. 

VHA Handbook 1143.2 dated June 4, 2004, mandates that a CNH Oversight Committee 

be established by the Medical Center Director, and that it report to the chief clinical 

officer. The committee should include multidisciplinary management-level 

representatives from social work, nursing, quality management, acquisition, and medical 

staff and should meet at least quarterly. Although the medical center had established an

inspection team, they had no Oversight Committee to review inspection results, discuss 

contract renewals, and monitor clinical and billing concerns. The medical center 

established a committee just prior to our site visit. 

VHA policy also requires that each VA CNH inspection team and Oversight Committee 

establish a working relationship with the appropriate Veterans Benefits Office and the 

local Ombudsman office to discuss subjects of mutual interest and concern. At a 

minimum, a yearly meeting should be held with each office. The VA CNH Program 

coordinator had his first meeting with the Ombudsman just prior to our site visit. The 

facility CNH Oversight Committee policy, created May 18, 2006, also includes this 

annual meeting as a Program requirement. 

An Oversight Committee provides oversight of CNH Program operations to ensure fiscal

accountability, procedural compliance, and quality of clinical care. In addition, the 

Committee monitors contract nursing facility performance improvement activities and

actions taken to correct deficiencies. As the local policy established a system of 

reporting to ensure ongoing compliance with Oversight Committee requirements, we 

made no recommendations related to policy compliance. 

Recommended Improvement Action(s) 1. The VISN Director should ensure that the 

Medical Center Director requires that: (a) VA CNH Program nurses visit patients in 

contract facilities no less than quarterly, and as clinically appropriate and (b) VA CNH 

Program staff increase monitoring of substandard nursing facilities where veterans 

remain under contract care. 

The VISN and Medical Center Directors agreed with the findings and recommendations 

and provided acceptable improvement plans. The CNH Program Coordinator will ensure 

that the CNH Program nurse visits patients quarterly, and that CNH Program staff 

increase monitoring of substandard nursing facilities until deficiencies are corrected. 

VA Office of Inspector General 5 
Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

Managers convened an administrative board of investigation (ABI) to review nursing 

visitation issues. We will follow up on the corrective actions. 

Quality Management – Some Processes Needed Improvement 

The purposes of this review were to determine if: (a) the medical center had a 

comprehensive, effective QM program designed to monitor patient care activities and

coordinate improvement efforts; (b) senior managers actively supported and 

appropriately responded to QM efforts; and (c) the medical center was in compliance 

with VHA directives, appropriate accreditation standards, and Federal and local 

regulations. The QM review included a self-assessment of the QM program completed

by the quality manager and interviews with senior management staff. With the exception 

of the following conditions needing improvement, we found that QM staff were

supported by senior managers in effectively monitoring patient care activities. 

Conditions Needing Improvement. Peer Review, Root Cause Analysis (RCA), and 

ABI processes needed improvement. 

Peer Review Process. Peer review is a confidential, non-punitive, and systematic process 

to evaluate quality of care at the individual provider level. A Peer Review Committee 

(PRC) conducts peer reviews, notifies the Chief of Staff (COS) when the matter being 

reviewed raises concerns about the possibility of substandard care, and recommends 

actions needed to protect patients. The PRC should meet quarterly, report at least 

quarterly to the Executive Committee of the Medical Staff, and track peer review 

activities. 

Peer review tracking had not been completed as required between July 2005 and June 

2006. VHA Directive 2004-054, Peer Review for Quality Management, and Medical 

Center Memorandum 11-40, Peer Review Program, requires quarterly tracking of peer 

review activities. Quarterly peer review tracking should include the number of 

completed reviews, the outcome by level (1, 2, or 3), the number of changes from one 

level to another during the review process, follow-up on action items, and 

recommendations that result from completed peer reviews. Without tracking of peer 

review activities, there is no assurance that trends and/or patterns related to patient

treatment outcomes will be identified. 

In addition, we found that the PRC had not met since November 2005. The COS told us 

that he suspended the meetings to protect the confidentiality of the peer review 

proceedings after the Office of Resolution Management (ORM), in its investigation of an

Equal Employment Opportunity (EEO) complaint, requested information from PRC 

meetings. Peer review proceedings are protected by Title 38, USC Section 5705. When 

conducted systematically and credibly, peer review can result in both immediate and 

long-term improvements in patient care by revealing areas for improvement in individual

VA Office of Inspector General 6 
Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

providers’ practices. This contributes to organizational performance and optimal patient 

outcomes. 

The COS acknowledged the importance of peer review activities and told us he will 

resume the meetings, but stated that he will not disclose protected information to ORM. 

As the peer review process will be resumed, we made no recommendations. 

RCA Process. In our review of the individual RCAs conducted between July 2005 and 

April 2006, we found 4 of 10 did not reflect measurable outcomes and/or did not measure 

the effectiveness of actions taken. In addition, 7 of 10 did not include all concurrence 

signatures. VHA Handbook 1050.1, VHA National Patient Safety Improvement

Handbook, and Medical Center Memorandum 11B-1, Patient Safety Improvement 

Program, require that once an action plan is implemented, there must be a plan for 

evaluating the effectiveness to assure that changes have the desired effect. Also they

require that the RCA is completed as evidenced by the concurrence signatures of all 

appropriate staff. Without evaluation of outcomes, patient safety effectiveness and 

improvement cannot be determined. Without signatures by all appropriate staff, there 

cannot be assurance of concurrence with the RCA findings or the plan for improvement.

In our previous CAP report, we also suggested the medical center improve RCA followup to determine the effectiveness of actions taken. 

ABI Process. In our review of all ABIs involving patient care allegations conducted 

between July 2005 and April 2006, we found that two of the six did not have all ABI 

team member signatures, and none of the six included the convening authority (medical 

center director) certificate of completion. VHA Handbook 0700, Administrative 

Investigations, requires the signature of all ABI team members on the report. If a team 

member is unable to sign, a statement explaining the reason should be included with the

report. The signatures indicate the report accurately reflects the investigation and that 

each finding of fact, conclusion, and recommendation reflects the view of a majority of 

the ABI members. Additionally, the Handbook requires the Medical Center Director to 

certify proper investigation and completion of the ABI in accordance with VHA 

requirements. The certificate of completion includes an opportunity for the medical 

center director to modify or comment on the findings of the ABI report, as well as note 

corrective action taken. The signature of all team members and the certificate of 

completion certify that the accuracy and completeness of the ABI has been verified. 

Recommended Improvement Action(s) 2. The VISN Director should ensure that the 

Medical Center Director requires that: (a) the PRC completes quarterly tracking of peer

review activities as required by policy, (b) RCAs have measurable outcomes and 

effectiveness of actions is evaluated, (c) RCA team members sign completed RCAs, and 

(d) there are certificates of completion on all ABIs and all members sign the completed 

reports. 

VA Office of Inspector General 7 
Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

The VISN and Medical Center Directors agreed with the findings and recommendations 

and provided acceptable improvement plans. PRC finding summaries will now include 

trending of peer review cases with level 2 and 3 findings. Managers implemented an 

action plan to improve the RCA process which included staff training, VISN level 

review, and local RCA action tracking. Managers will ensure that ABI and RCA reports 

have completion certificates and/or signatures prior to closure. We will follow up on the 

corrective actions. 

Environment of Care -– Follow-Up to a Previously Identified 

Deficiency Was Insufficient 

To assess the safety and cleanliness of the medical center, we inspected six patient care 

areas, selected public areas, and the Food and Nutrition Service (F&NS) kitchen. 

Overall, we found the medical center to be clean and appropriately maintained. Some

minor issues, such as malodorous bathrooms, a loose wall-hung sink, and dusty 

unoccupied beds were corrected before we left the site. Managers provided us with 

completed work orders for other identified issues. However, we determined that 

managers did not follow up on one corrective action taken in response to a patient safety 

deficiency identified in the 2005 annual workplace evaluation (AWE) report. This 

condition requires management attention. 

Condition Needing Improvement. The 2005 AWE report noted dirty air diffusers 

(outlets or grilles designed to direct air flow in specific patterns) in the ceiling of the main 

F&NS kitchen and recommended scheduled monthly cleaning. The main F&NS kitchen

ceiling and air diffusers were not clean at the time of our inspection. We found 7 of 29 

(24 percent) air diffusers were dirty with dust balls visible in an 8–10 foot radius on the 

ceiling. The F&NS kitchen prepares food for all patients, and cleanliness is essential to 

patient health and safety. 

Recommended Improvement Action(s) 3. The VISN Director should ensure that the 

Medical Center Director requires that F&NS kitchen ceiling and air diffusers be cleaned 

regularly and a monitoring system put into place to ensure compliance. 

The VISN and Medical Center Directors agreed with the findings and recommendations 

and provided acceptable improvement plans. Medical center managers implemented an 

action plan including regularly scheduled cleaning, annual preventative maintenance, and 

monitoring to ensure the cleaning is completed as scheduled. We will follow up with the 

corrective actions. 

VA Office of Inspector General 8 
Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

Other Focused Review Results 

Diabetes and Atypical Antipsychotic Medications – Monitoring and 

Treatment Are Appropriate 

Medical center clinicians performed effective diabetic 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 screening patients who are at risk for 

the development of diabetes suggest that fasting blood glucose (FBG) is the preferred

screening test. The medical center’s value for normal FBG was less than or equal to 115 

mg/dl. We reviewed a sample of 13 patients who were on one or more atypical 

antipsychotic medications for at least 90 days in FY 2005. Two of the 13 patients were 

diabetic and appropriately managed. Clinicians obtained FBGs on 10 of the 11 nondiabetic patients. 

Appropriate screening also includes assessment of risk factors such as family history of

diabetes, overweight, abnormal blood glucose, and hypertension. We found that only 1 

of the 11 non-diabetic patients in our sample was questioned about a family history of

diabetes. While we were onsite, the medical center developed a clinical reminder on

diabetic risk factors for clinicians prescribing atypical antipsychotic medications; 

therefore, we did not make any recommendations. 

Breast Cancer Management – Patients Are Managed Appropriately

The medical center met the VHA performance measure for breast cancer screening, 

provided timely Surgery and Oncology consultative and treatment services, promptly

informed patients of diagnoses and treatment options, and developed coordinated 

interdisciplinary treatment plans. 

The VHA breast cancer screening performance measure assesses the percent of patients 

screened according to prescribed timeframes. The following table illustrates the medical 

center’s breast cancer screening performance. 

VA Office of Inspector General 9 
Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

Breast Cancer Screening

Salisbury VAMC

89 90

87

81

85 86 84 86

90

100

94

100

92

96

88 91

83 84

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

Qtr 1_05 Qtr 2_05 Qtr 3_05 Qtr 4_05 Qtr 1_06 Qtr 2_06

Percent

Facility

VISN

National

FY 2005 & FY 2006 

Performance Measure Scores

Fully Satisfactory

Score = 85%

All four patients diagnosed with breast cancer during FY 2005 had screening 

mammograms. Patients received timely biopsies, consultations, and treatments. 

Clinicians communicated well with patients, keeping them informed of test results and 

involving them in the treatment planning process. We found patient care was well 

coordinated from the time of presentation with symptoms (or for screening) to conclusion 

of treatment. 

Patient Satisfaction – Managers Are Addressing Deficiencies 

The 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 treated and 76 percent of inpatients 

discharged during a specified date range will report their experiences as very good or 

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

underperforming. The following graphs show the medical center’s (or clinics’s) 

performance in relation to national and VISN performance. 

VA Office of Inspector General 10 
Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

Salisbury Inpatient SHEP Results 

Q3 and Q4 FY05 

Inpatient - 3Q and 4Q 

FY05 

Access 

Coordination

of Care

Courtesy 

Education & 

Information 

Emotional Support 

Family Involvement 

Physical Co

mfort 

Preferences 

Transition 

National 80.73 78.27 89.40 67.36 65.08 75.37 83.35 73.98 69.52 

VISN 82.30 80.30 89.70 69.30 66.70 75.10 83.50 74.90 71.60 

Medical Center 85.50 81.90 89.50 66.90 65.60 76.20 86.40 73.00 60.70 

Salisbury Outpatient SHEP Results 

Q1 FY06 

Outpatient - 1Q 2006 

Access 

Continuity of

Car

e

Courtesy 

Education & 

Information 

Emotional 

Support 

Overall 

Coordination

Pharmacy 

Mailed 

Pharmacy 

Pick-u

p

Preferences 

Sp

ecialist

 Care 

Visit 

Coordination

National 81.5 78 95.3 73.1 83.7 76.2 82.6 66.5 82.2 80.7 85.2 

VISN 78.9 77.7 95 72 82.8 74.2 83.1 60.7 80.4 81.7 83.7 

OUTPATIENT CLINIC Overall 81.7 87.9 93 74 83.7 73.9 91.5 69.6 80.4 81 82.1 

 SALISBURY 81.2 89 94.1 73.6 82.5 71.1 91.6 64.5 80.2 81.6 81 

 WINSTON-SALEM 83.7 86.2 90.6 77 87.7 80 * 78.6 81.7 81.1 85.3 

 CHARLOTTE 77.7 84.6 92.1 65.6 77.6 74.3 91.8 * 76.8 72.8 79.5 

* signifies fewer than 30 respondents 

The medical center has a designated SHEP Coordinator who analyzes SHEP results. 

Several areas were identified for improvement, and corrective action plans were

developed to address education and information, emotional support, preferences, 

transition, overall coordination, and pharmacy. Some examples of the improvement 

initiatives include: increased use of Krames On-Demand, a commercially available, 

electronic print-on-demand library of patient education materials; increased use of patient 

information racks with educational pamphlets; development of Quick Cards patients use 

to assess their visit to the medical center using actual SHEP questions; creation of maps 

to assist patients in the location of clinic areas; and development of performance 

improvement initiatives to lead to improved patient satisfaction. 

VA Office of Inspector General 11 
Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

Appendix A 

VISN Director Comments

Department of 

Veterans Affairs Memorandum

Date: August 7, 2006 

From: Director, Mid-Atlantic Healthcare Network (10N6) 

Subject: Combined Assessment Program Review of the W.G. 

(Bill) Hefner VA Medical Center Salisbury, North 

Carolina, Report Number, 2006-02245-HI-0360 

To: Director, Office of Inspector General (53B) 

1. The attached subject report is forwarded for your 

review and further action. I have reviewed the responses 

and concur with the facility's recommendations. 

2. Please contact Donald Moore, Director, VAMC 

Salisbury at (704) 638-9000 ext. 3344 if you have any 

questions. 

 (original signed by:)

Daniel F. Hoffmann, FACHE 

VA Office of Inspector General 12 
 Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

Appendix B 

Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum

Date: August 7, 2006 

From: Director, W.G (Bill) Hefner Medical Center (659/00) 

Subject: Combined Assessment Program Review of the W.G. 

(Bill) Hefner VA Medical Center Salisbury, North 

Carolina, Report Number 2006-02245-HI-0360

To: Director, Office of Inspector General (53B) 

Network Director, VA Mid-Atlantic Health Care 

Network, VISN 6 

1.This is to acknowledge receipt and thorough review of

the Office of Inspector General Combined Assessment 

Program Review draft report. I concur with all 

recommendations for improvement identified in the

report. 

2.The responses and action plans for each 

recommendation are enclosed. 

3. Should you have any questions regarding the comments 

or implementation plans, please contact me at (704) 638-

9000 ext. 3344. 

 (original signed by:)

DONALD F. MOORE, R.Ph, MBA 

Medical Center Director 

VA Office of Inspector General 13 
Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

Director’s 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 Recommendation(s)

Recommended Improvement Action(s) 1. The VISN

Director should ensure that the Medical Center Director 

requires that: 

a. VA CNH Program nurses visit patients in contract 

facilities no less than quarterly, and as clinically appropriate. 

Concur Target Completion Date: Completed. 

The CNH Coordinator has been assigned responsibility for 

ensuring that the CNH Program Nurse visits patients in 

contract facilities no less than quarterly. The CNH Program 

Coordinator has also been assigned responsibility to ensure 

that a CNH Program Nurse makes additional visits for any 

clinical trigger, as outlined in Section 9 of VHA Handbook

1143.2, dated June, 2004. The CNH Program Nurse has 

visited all Salisbury VA patients in CNHs in late June and 

early July, 2006, with the exception of one facility which had 

already been visited by the Durham VA CNH Program Nurse

during this quarter. 

An Administrative Board of Investigation was initiated to 

investigate prior performance deficiencies of the CNH 

Program Nurse. Findings and recommendations are due to 

the Medical Center Director on August 25, 2006. 

b. VA CNH Program staff increase monitoring of 

substandard nursing facilities where veterans remain under 

contract. 

Concur Target Completion Date: Completed. 

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Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

All veterans in substandard contract nursing facilities will be 

monitored at an increased frequency until all deficiencies 

have been corrected. The CNH Program Coordinator has 

established an electronic tickler file to ensure the timely 

completion of the increased monitoring. The five substandard

facilities were all visited by the CNH Program Nurse in early

July, 2006. Those facilities that remain rated as substandard 

by state, will continue to be monitored at the increased 

frequency of a monthly CNH Program Nurse visit, in addition 

to a monthly CNH Social Worker visit, until the deficiencies 

have been corrected. This increased monitoring will be 

reported to the Contract Nursing Home Oversight Committee, 

with minutes to the Clinical Executive Board. 

Recommended Improvement Action(s) 2. The VISN

director should ensure that the Medical Center Director 

requires that: 

a. The PRC completes quarterly tracking of peer review 

activities as required by policy. 

Concur Target Completion Date: Completed. 

A summary of Peer Review Committee findings, including 

tracking the number of reviews, level of outcomes, changes in 

levels, action item follow-ups, and recommendations will 

continue to be presented to the Clinical Executive Board, but 

now includes trending of the types of cases that resulted in 

level 2 and 3 findings. Such a comprehensive summary of all 

the FY05 Peer Review Committee findings was presented at

the July 26, 2006 Clinical Executive Board meeting. 

b. RCAs have measurable outcomes and effectiveness of

actions is evaluated. 

Concur Target Completion Date: Completed. 

In an effort to improve staff abilities related to drilling down 

to the root causes of events, strengthening actions and 

ensuring that actions are measurable, training has been 

scheduled by the VISN 6 Patient Safety Officer for all VISN 

6 Patient Safety Managers and their primary back-ups in 

September 2006. The agenda for this training will include: 

VA Office of Inspector General 15 
Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

• Developing More Meaningful Root 

Cause/Contributing Factor Statements 

• Writing Stronger Action Plans 

• Improving measurements (Increasing Objective 

Measurement) 

In addition, there is now a VISN 6 plan in place to review 

action plans and measurements of selected Root Cause 

Analyses within the network Patient Safety peer group. 

During monthly VISN Patient Safety conference calls, each 

facility Patient Safety Manager has been encouraged to share 

recently completed RCAs. The goal of this process is to 

share experiences, information, and ideas in an effort to 

strengthen actions and ensure measurability. The VISN

Patient Safety Officer is also available to review root cause 

statements and action plans as requested by the facility 

Patient Safety Manager. 

Within the Salisbury VAMC, actions and measurements are 

reviewed with the individuals who will be responsible to 

implement the actions and make the measurements during the 

conduct of the RCA. The status of measurements is tracked 

on a tracking sheet maintained in the Office of Performance 

and Quality. Responsible individuals are reminded of actions 

and measurements due at intervals prior to due dates by the 

Patient Safety Manager. The tracking record is updated 

monthly in the Office of Performance and Quality and any 

overdue actions or measures are forwarded to the appropriate 

service line for intervention. This information is reviewed at 

the Clinical Executive Board (CEB). 

c. RCA team members sign completed RCAs. 

Concur Target Completion Date: Completed. 

The team leader of each root cause analysis (RCA) has the 

responsibility to obtain all signatures of appropriate staff. 

The team leader will be instructed and reminded by the 

Patient Safety Manager to obtain the signatures prior to the 

discussion with the Medical Center Director. 

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Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

d. There are certificates of completion on all ABIs and all 

members sign the completed reports. 

Concur Target Completion Date: Completed. 

The following statement has been added to the

Recommendation Sheet signed by the Director after the 

review, presentation and discussion of each Administrative 

Board of Investigation:

“I have conducted a review of the attached report of 

investigation dated (Report date) into (Subject from Charge 

Letter) in accordance with VA Handbook 0700. This 

investigation was convened by my charge letter of ________,

2006. 

I certify that this report has been reviewed for compliance 

with VA Directive and Handbook 0700, and the subject of the 

report has been properly investigated.” 

____________________ ____________ 

Convening Authority Date 

In addition, the Chair of each ABOI will be instructed that all

signatures must be obtained prior to the presentation and 

discussion of the investigation. No investigations will be 

signed as completed until all signatures are obtained 

Recommended Improvement Action(s) 3. The VISN

Director should ensure that the Medical Center Director 

requires that the F&NS kitchen ceiling and air diffusers are 

cleaned regularly and a monitoring system put into place to 

ensure compliance. 

Concur Target Completion Date: Completed. 

The following action plan has been put in place to ensure that 

the kitchen diffusers stay clean and free of dirt: 

a. Nutrition and Food Service has included the diffusers on 

their regular cleaning schedule. The surface of the diffusers 

and surrounding ceiling will be cleaned and dusted monthly. 

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Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina 

b. Facilities Management has included the diffusers in the 

preventive maintenance program for the Utility Shop. These 

diffusers and associated duct work will be cleaned annually. 

This will be accomplished by writing a service to a contractor 

who specializes in duct/diffuser cleaning. 

c. Nutrition and Food Service and Facilities Management 

will jointly monitor the diffusers to ensure that the cleaning is 

completed as scheduled. 

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Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Christa Sisterhen, Associate Director 

Atlanta Office of Healthcare Inspections 

(404) 929-5961 

Acknowledgments Susan Zarter, Healthcare Inspections Team Leader 

Victoria Coates 

Bertha Clarke 

Steve Fulmer 

Toni Woodard 

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Combined Assessment Program Review of the W.G. (Bill) Hefner VAMC Salisbury, North Carolina

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Mid-Atlantic Healthcare Network (10N6) 

Director, W. G. (Bill) Hefner VA Medical Center (659/00) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Quality of Life and Veterans Affairs 

House Committee on 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: Elizabeth Dole, Richard Burr 

U.S. House of Representatives: Howard Coble, Melvin L. Watt 

This report will be available in the near future on the OIG’s Web site at 

http://www.va.gov/oig/52/reports/mainlist.htm. This report will remain on the OIG Web 

site for at least 2 fiscal years after it is issued. 

VA Office of Inspector General 20