Department of Veterans Affairs 

Office of Inspector General 

Combined Assessment Program 

Review of the G.V. (Sonny) Montgomery 

VA Medical Center 

Jackson, Mississippi 

Report No. 06-01520-211 September 15, 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. 

• Determine if management controls ensure compliance with regulations and VA

policies, assist management in achieving program goals, and minimize 

vulnerability to fraud, waste, and abuse. 

• 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 G. V. (Sonny) Montgomery VAMC Jackson, MS

Contents 

Page 

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

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

Healthcare System Profile ............................................................................................... 1

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

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

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

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

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

Quality Management.................................................................................................... 5

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

Contract Nursing Homes.............................................................................................. 8

Other Observations.......................................................................................................... 9

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

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

Appendixes 

A. VISN and Medical Center Director Comments....................................................... 13

B. OIG Contact and Staff Acknowledgments............................................................... 19

C. Report Distribution................................................................................................... 20

VA Office of Inspector General 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

Executive Summary 

Introduction 

During the week of May 22, 2006, the Office of Inspector General (OIG) conducted a 

Combined Assessment Program (CAP) review of the G.V. (Sonny) Montgomery VA 

Medical Center (VAMC or medical center). The purpose of the review was to evaluate 

selected system operations, focusing on quality management (QM), and selected areas of 

patient care. During the review, we also provided fraud and integrity awareness training 

to 169 employees. The medical center is under the jurisdiction of the Veterans Integrated 

Service Network (VISN) 16. 

Results of Review 

This CAP review focused on six healthcare areas. The system 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: 

• Hurricane Katrina Response Efforts 

• Governance Council 

• Advanced Clinic Access Initiative 

We made recommendations in four of the six activities reviewed. For the activities of 

Environment of Care, Quality Management, Breast Cancer Management, and Contract 

Nursing Homes (CNH), the medical center needed to: 

• Ensure the safety of psychiatric patients subject to improperly draining bathroom

showers. 

• Perform and document specially required fire drills. 

• Ensure all 30-day mortalities and major morbidities associated with surgical 

procedures undergo peer review. 

• Comply with patient safety goals to ensure correct surgery guidelines are followed for 

invasive procedures performed in non-operating room settings. 

VA Office of Inspector General i 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

• Comply with Veterans Health Administration (VHA) Handbook 1400.1 to ensure

surgical resident supervision is properly documented. 

• Implement a process for communication of suspicious or abnormal mammography

reports to patients and from off-site affiliates. 

• Document patient notification of mammography results in patient’s medical records. 

• Implement a policy to require use of VHA-recommended documents and forms for its 

CNH program. 

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

Mr. Raymond Tuenge, Associate Director, St. Petersburg Office of Healthcare 

Inspections. 

VISN and Medical Center Director Comments 

The VISN Director and the Medical Center Director agreed with the CAP review 

findings and recommendations and provided acceptable improvement plans. See 

Appendix A, beginning on page 13 for the full text of the Directors’ comments. We will 

follow up on implementation of 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 G. V. (Sonny) Montgomery VAMC Jackson, MS

Introduction 

Healthcare System Profile 

Organization. Located in Jackson, MS, the medical center consists of a tertiary care 

facility, a long-term care center, and community based outpatient clinics located in 

Meadville/Natchez, Meridian, Greenville, Kosciusko, Columbus, and Hattiesburg, MS. 

The medical center is part of VISN 16 and serves a veteran population of 132,000,

including over 11,000 female veterans, in 50 counties in Mississippi and 6 parishes in 

Louisiana. 

Programs. The medical center provides comprehensive outpatient, medical, surgical,

psychiatric, and nursing home care services. Additionally, it has programs in physical 

medicine and rehabilitation, neurology, oncology, radiation therapy, and dentistry. The 

medical center has 148 hospital beds, 120 nursing home beds, and 15 substance abuse

residential program beds. It is a referral center for cardiology, bariatric surgery, and 

cancer care. 

Affiliations and Research. The medical center is affiliated with the University of 

Mississippi Medical School. It also has affiliations with 20 other university and college

programs in nursing, dentistry, pharmacy, physical and occupational therapy, psychology, 

cytotechnology, medical technology, nuclear medicine, radiology, and health care 

administration. 

Currently, the medical center has 84 approved research projects with 38 principal 

investigators. Major areas of research include hypertension, mental health and health 

promotions, and diabetes. 

Resources. The medical center’s budget in fiscal year (FY) 2005 was approximately 

$192 million and over $207 million in FY 2006. FY 2006 staffing was 1,700 full-time 

equivalent employees (FTE), which included 137 physician and 759.75 nursing FTE. 

Workload. In FY 2005, the medical center treated 47,632 unique patients; in FY 2006 

(through April 30, 2006), it treated 46,043 unique patients. In FY 2005, the average daily 

census was 105 Hospital/Residential and 117 Nursing Home, and in FY 2006 (through 

April 2006), the average daily census was 99 Hospital/Residential and 116 Nursing 

Home. The FY 2006 (through April 30, 2006) outpatient workload was 227,740 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 and benefits services. The 

objectives of the CAP review are to: 

VA Office of Inspector General 1 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

• Conduct recurring evaluations of selected health care facility operations focusing on

patient care, quality management, benefits, and financial and administrative controls. 

• 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 activities to evaluate the effectiveness of Quality 

Management and patient care administration. We also conducted an inspection of the 

medical center’s environment of care. QM is the process of monitoring the quality of 

patient care to identify and correct harmful practices or conditions. Patient care

administration is the process of planning and delivering patient care. Environment of 

care 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 interviewed managers, employees, and patients; and 

reviewed clinical and administrative records. This review covered the following 

activities: 

Quality Management Program Environment of Care 

Contract Nursing Homes Breast Cancer Management 

Diabetes and Atypical Antipsychotic 

 Medications 

Survey of Healthcare Experiences 

 of Patients (SHEP) 

The review covered facility operations for FY 2004 and FY 2005 and was done in 

accordance with VA OIG standard operating procedures for CAP reviews.

During the review, we also presented 4 fraud and integrity awareness briefings for 169 

employees. These briefings covered procedures for reporting suspected criminal activity 

to the OIG and included case-specific examples illustrating procurement fraud, false 

claims, 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. We also noted several organizational strengths of the medical center 

during the course of the review, and we have included a brief description of these 

organizational strengths in this report. 

VA Office of Inspector General 2 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

Results of Review 

Organizational Strengths 

Hurricane Katrina Response Efforts. The medical center provided invaluable emergency 

and transition assistance both to victims and to VA employees in response to Hurricane 

Katrina’s impact on the Gulf Coast in August 2005. For the first 4 months of FY 2006, 

the medical center served 6,772 unique veterans from Katrina disaster areas in 

Mississippi, Alabama, and Louisiana. In October and November 2005, the medical 

center’s unique patient workload was 12 percent greater than the same 2-month period in 

FY 2005. Total outpatient visits and primary care visits were 7.4 percent and 13.75 

percent higher, respectively. Prior to the hurricane, the majority of Biloxi VAMC 

specialty care patients were referred to New Orleans VAMC. In the aftermath of Katrina, 

however, many Biloxi VAMC as well as New Orleans VAMC specialty care patients 

were referred to Jackson VAMC. In September and November 2005, for example, 336 

surgical consults were referred from Biloxi and New Orleans. The medical center’s 

administrative workload also increased significantly. In the 6 months following Katrina, 

the medical center provided human resources and fiscal support for hundreds of displaced 

New Orleans medical center staff. The medical center provided employment for 

approximately 150 New Orleans VAMC personnel and assisted their transition to new 

employment and relocation. 

Governance Council. The medical center has an excellent executive management 

structure that utilizes a Governance Council made up of its top executives to establish 

policy, develop strategic plans, provide performance oversight, and review resource and 

safety/quality management measures. As the medical center’s senior interdisciplinary 

committee, the Governance Council meets bi-monthly to comprehensively review all 

medical center organizational activities. As such, the Governance Council functions both 

to provide oversight to other medical center committees and to coordinate their activities. 

The Governance Council uses an interdisciplinary reporting mechanism that tracks

actions arising from all medical center management committees and service areas to 

ensure that issues are effectively addressed. The Governance Council structure assures 

that medical center executives provide effective leadership; it also requires them to 

assume full responsibility for all medical center clinical and administrative operations. 

Advanced Clinic Access Initiative. The medical center has committed itself to the 

principles of Advanced Clinic Access (ACA), VA’s national project to reduce patient

waiting times and delays in outpatient clinics. The medical center has recruited two ACA 

Coordinators dedicated to implementation of the ACA practices throughout the medical 

center and its community clinics. The positive effect of the medical center’s 

implementation of ACA has been demonstrated in FY 2005 overall performance 

measures, specifically by its ranking second in VISN 16 for quality and satisfaction, in 

which wait times are an integral component. 

VA Office of Inspector General 3 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

Opportunities for Improvement 

Environment of Care 

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

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

all patient care areas and found that the medical center was generally clean with 

environmental employees demonstrating clear “pride of ownership” for their assigned 

work areas. We identified some general cleanliness issues that required management

attention in inpatient areas involving dusting, ongoing interior maintenance, cleaning of 

clinical equipment, and replacement of damaged furniture. The Chiefs of Facility 

Management Service and Environmental Management Service were informed and 

initiated immediate corrective actions for these minor issues. We found additional 

Environment of Care (EOC) issues requiring further management attention for which we 

are making recommendations for improvement. 

Improper Shower Drainage. We found that inpatient psychiatric bathroom floors were 

poorly designed, resulting in inadequate shower drainage. The medical center had 

redesigned and renovated the bathrooms using a design intended to optimize safety for 

psychiatrically compromised inpatients. However, the floor areas do not contain the flow

of water from the shower area into the single floor drain. Water drains out into the main 

bathroom floor and continues out into the patient rooms, thus creating a slip and fall risk. 

The medical center was aware of this issue and has received tentative budget approval for 

a Minor Construction project to renovate the shower areas, but the renovation will not

take place until FY 2009. 

Interim Life Safety Measures. We found data in the Safety Office that there were Interim 

Life Safety Measures (ILSM) in place at the medical center. The facility managers 

elected to conduct two fire drills per shift per quarter in those areas that were under

ILSM. We reviewed the medical center’s October 2005 through June 2006 EOC 

minutes, but found no documentation in the minutes that would validate adherence to 

ILSM Life Safety Code criteria (EC 5.5) because of the following: 

• In the Construction Risk Assessment section (III.B.), the EOC Committee did not 

identify the construction projects that had ILSM criteria in effect during the 

reporting period. Furthermore, we found no additional explanation, data, or 

information on any ILSM conditions or duration in the ILSM section (VIII.D.). 

• Under the Fire Safety-Fire Drill section (VIII.A.), fire drills conducted during the 

reporting period are documented; however, we could not identify the additional 

fire drills conducted within areas having ILSM conditions. 

VA Office of Inspector General 4 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

• There is no discussion or data provided through the EOC Committee that details 

the existence of any ILSM condition(s) within any construction area at the medical 

center. 

Recommended Improvement Actions 1. The VISN Director should ensure that the 

Medical Center Director requires that (a) appropriate measures are taken to ensure the 

safety of psychiatric patients until bathrooms are renovated to correct improperly 

draining showers and (b) ILSM-mandated fire drills are separately identified and 

reviewed by the EOC Committee. 

Quality Management Program Review 

Condition Needing Improvement. The medical center’s QM program was 

comprehensive and generally effective. However, we found four areas where 

performance improvements were needed. 

Peer Reviews. VHA policy1 requires a formal peer review of all mortalities and major 

morbidities associated with any surgical procedures within 30 days. We reviewed 

surgical mortality and morbidity reports for the period March 2005 through March 2006.

We found that, for the 48 surgical deaths that occurred within 30 days of surgery at the 

medical center during that 12-month period, peer reviews were completed on only 32 (67

percent). 

Ensuring Correct Surgery. The medical center was cited by the Joint Commission on

Accreditation of Healthcare Organizations (JCAHO) in September 2005 for 

inconsistency in the process for ensuring correct surgery in non-operating room (OR)

settings where invasive procedures are performed. VHA Directive 2004-028 provides 

guidelines to be applied to invasive procedures outside the OR to ensure that such 

invasive procedures are performed on the correct patient, at the correct site, and if 

applicable, with the correct implant. We reviewed data showing a compliance rate of 88 

percent for non-OR invasive procedures during the period September 15 through 

December 15, 2005. The medical center’s executive summary for FY 2006 shows that 

the compliance rate for non-OR procedures was 83 percent despite education efforts by 

the medical center. 

Resident Supervision. Lack of documentation of resident supervision was cited in the 

Peer Review Annual Report for March 2006. Specifically, residents were not 

documenting the reasons for being called during off-duty hours and were not notifying 

the attending physician as required. This triggered a review of resident supervision 

documentation that showed a compliance rate of 55 percent for FY 2005 and 67 percent 

for the first half of FY 2006. At the time of our review in May 2006, the medical center 

had initiated intensive efforts to improve documentation of resident supervision. As a 

 1

 VHA Directive 2004-054, Peer Review for Quality Management, September 29, 2004. 

VA Office of Inspector General 5 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

result of the education efforts and monitoring, the medical center had a 94 percent 

compliance rate for Surgical Service for the period May 1–22, 2006. Further data will be 

needed to determine if improvement in compliance continues. 

Recommended Improvement Actions 2. We recommended that the VISN Director 

ensure that the Medical Center Director takes action to: (a) ensure all 30-day mortalities 

and major morbidities associated with surgical procedures undergo peer review, (b) 

comply with patient safety goals to ensure correct surgery guidelines are followed for 

invasive procedures outside the OR setting, and (c) comply with VHA Handbook 1400.1 

to ensure surgical resident supervision is properly documented. 

Breast Cancer Management 

Condition Needing Improvement. Although the medical center met the VHA 

performance measure for breast cancer screening in all 4 quarters for FY 2005, we found 

that the medical center’s off-site contract affiliate did not provide results and notify 

patients as required by VHA policy.

2

 Mammography results were not reported to patients 

within required timeframes, and there was a lack of documentation that the off-site 

affiliates forwarded results to the medical center within required timeframes. In addition, 

patient notification of mammography performed by the off-site was not documented in 

patient medical records as required by VHA policy. 

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

screened according to prescribed timeframes. The chart below shows the VHA’s breast

cancer management performance for FY 2005: 

G.V. (SONNY) MONTGOMERY VAMC

JACKSON, MS

94 93

91

83

85 86

100 100 100 100

89

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%

 2

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

VA Office of Inspector General 6 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

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

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

outcomes. VHA mammography standards require normal findings to be documented in

the medical record within 30 days of the procedure. Suspicious or abnormal results must 

be communicated to the ordering provider within 3 working days. Timely results need to

be available and accessible to guide patient care and treatment. Furthermore, results must 

be communicated to patients within 30 days if normal and within 5 days if the results are

suggestive of malignancy. We assessed these items in a review of nine patients who were

diagnosed with breast cancer or had an abnormal mammography during FY 2005, FY 

2004, and FY 2003. The results are shown in the table below: 

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 

7/9 8/9 4 /7 4/4 6/6

Clinicians generally had developed coordinated interdisciplinary treatment plans and 

provided timely Surgery and Hematology/Oncology consultative and treatment services. 

However, we determined through further review of medical records that three of seven

patients (the other two patients were diagnosed at private facilities) were not notified of 

their mammography results. Furthermore, patient notifications of mammography

performed off-site were not documented in the patients’ medical records. 

The medical center has a contract with an off-site affiliate to provide mammograms for 

their patients. We found that communication between the affiliate and the medical center 

was inadequate to ensure that procedures were completed and the affiliate notified

patients according to Mammography Quality Standards Act and VHA policy. We also

found that the medical center did not have a means to document that all the patients 

received timely notification of results. The medical center had no tracking system in 

process to monitor the patients who were having mammograms off-site. In April 2006, 

the medical center created a new position for a mammography coordinator to track 

patients receiving mammograms. The coordinator keeps track of signs of symptoms, 

schedules appointments, and follows up on results and further treatment. 

Recommended Improvement Actions 3. We recommend that the VISN Director ensure 

that the Medical Center Director takes action to (a) implement a process for 

communication of suspicious or abnormal mammography reports to patients and from

off-site affiliates as required in VHA Handbook 1104.1 and (b) document patient

notification of mammography and biopsy results in medical records. 

VA Office of Inspector General 7 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

Contract Nursing Homes 

Condition Needing Improvement. The medical center’s CNH program complied with 

VHA policies and was generally effectively managed. However, we found that program

could be improved through use of VHA’s recommended tools for documenting and 

coordinating CNH programs. 

The medical center had seven contracts with CNHs but did not have any patients in those

nursing homes at the time of our review. We reviewed policies, existing contracts, 

minutes of the CNH Oversight Committee, documentation of inspections for 6 CNHs, 

and medical records of 10 former CNH patients. We interviewed members of the CNH 

Inspection Team and the CNH Oversight Committee. 

We found that the medical center complied with VHA’s requirements for the CNH 

program.

3

 The CNH Inspection Team performed initial and annual facility inspections 

using its own internal forms for administrative, social services, and nursing areas. The 

CNH program social workers and nurses conducted monthly site visits to monitor the 

care of CNH patients. The medical center’s CNH Oversight Committee provided 

adequate managerial oversight for the program. 

Although the medical center currently does not have any patients in CNHs, we conducted 

a site visit to Tensas Nursing Home in Newellton, LA, during which we interviewed the 

Administrator and Director of Nursing (DON) and performed a limited inspection of the

facility’s environment of care. The Administrator and DON expressed a very high level 

of satisfaction with the professionalism and thoroughness of the medical center CNH 

staff with whom they interacted on an ongoing basis. We reviewed the files of two 

former VA patients during our site visit and found that the care provided by the CNH was 

well-documented and fulfilled the requirements of the contracts and medical center 

discharge orders. 

Although the medical center complied with VHA requirements in the performance and 

reporting of initial and annual CNH inspections, we found that the CNH program could 

be improved if the tools recommended by VHA were utilized. The medical center used 

separate forms to document the various components of initial and annual inspections, 

such as social work, engineering, and nursing inspections. The medical center did not

use the Exclusion Form recommended on the VHA website to document CNH 

inspections. The Exclusion Form serves to document all the critical aspects of patient 

care that, if not provided by the CNH, would exclude that CNH from VA participation. 

The Exclusion Form would thus provide the needed comprehensive documentation of the

facility inspections on a single form. The medical center also did not use the CNH 

adverse event form to document and report adverse events that occur at CNH facilities. 

 3

 VHA Handbook 1143.2, “VHA Community Nursing Home Oversight Procedures.” 

VA Office of Inspector General 8 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

Although we did not find that adverse events went unreported, use of the VHArecommended form would ensure that such occurrences are reported. 

During our review, the medical center prepared a draft policy that, once implemented, 

would require the use of the CNH Exclusion Form and Adverse Event Forms. 

Recommended Improvement Action 4. We recommended that the VISN Director

require the Medical Center Director to approve and implement the draft policy requiring 

the use of the VHA-recommended documents and forms for its CNH program. 

Other Observations 

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). Clinicians needed to improve blood 

pressure monitoring and control, review Fasting Blood Glucose (FBG) test results, and 

improve prevention counseling for patients without diabetes. 

VHA clinical practice guidelines for the management of diabetes suggests 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; blood 

pressure should be less than 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 fully satisfactory rating for these diabetes performance measures, the medical 

center must achieve the following scores: 

• HbA1c greater than 9 percent (poor Glycemic control) – Goal is 15 percent or

lower (lower percent is better). 

• Blood Pressure less than 140/90 mmHg – Goal is 72 percent or higher (higher

percent is better). 

• Cholesterol (LDL-C) less than 120 mg/dl – Goal is 75 percent or more (higher 

percent is better). 

VHA clinical practice guidelines for screening patients who are at risk for the 

development of diabetes suggests that FBG is the preferred screening test and should be

performed every 1-3 years. A normal FBG is less than 110 mg/dl. Patients with FBG 

values greater than 110 mg/dl but less than 126 mg/dl should be counseled about 

prevention strategies (calorie-restricted diets and exercise). A FBG value that is greater 

than 126 mg/dl on at least two occasions is diagnostic for Diabetes Mellitus. 

VA Office of Inspector General 9 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

We reviewed medical records for a sample of 13 patients who were on one or more 

atypical antipsychotic medications for at least 90 days. Only one of the patients had a

diagnosis of diabetes. Our review showed that the medical center met or exceeded VHA 

performance criteria for this diabetic patient, and the 12 applicable non-diabetic patients 

were appropriately screened and counseled. 

Diabetic 

patients with 

HbA1c greater 

than 9 percent 

Diabetic 

patients with 

B/P less than 

140/90 

mm/Hg

Diabetic patients 

with LDL-C less 

than 120mg/dl 

Non-diabetic 

patients 

appropriately 

screened 

Non-diabetic 

patients who 

received 

diabetes 

prevention 

counseling 

100 percent 

(1/1) 

0 percent 

(0/1) 

100 Percent 

(1/1) 

92 percent 

(11/12) 

100 percent 

(10/10) 

SHEP Evaluation 

Veteran patient satisfaction surveying is designed to promote health care quality 

assessment and improvement strategies that address patients' needs and concerns, as 

defined by patients. In 1995, VHA began surveying its patients using a standardized 

instrument modeled from the Picker Institute, a non-profit health care surveying group. 

The Performance Analysis Center for Excellence of the Office of Quality and 

Performance is the analytical, methodological, and reporting staff for SHEP. Measure 21 

of the VHA Executive Career Field Performance Plan for FY 2006 states that “In FY06

the percent of patients reporting overall satisfaction as Very Good or Excellent will meet 

or exceed targets” in: 

a. Ambulatory Care: 

Performance Period: Patients seen October 05–June 06 

 Meets Target: 77 percent 

 Exceeds Target: 80 percent 

b. Inpatients: 

Performance Period: Cumulative October 05–June 06 

 Meets Target: 76 percent 

 Exceeds Target: 79 percent 

Following are graphs showing the medical center’s SHEP results for inpatients and 

outpatients. 

VA Office of Inspector General 10 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

INPATIENT SHEP RESULTS 

Facility Name 

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 16 80.20 77.70 89.20 67.50 65.90 74.60 82.90 75.1+ 69.80

 JACKSON VAMC 84.2+ 81.5+ 91+ 75.1+ 69.9+ 79.5+ 82.10 77+ 74.4+

Jackson, MS 

VA Medical Center 

VAMC

FY2005 3rd & 4th Quarter 

OUTPATIENT SHEP RESULTS 

Access Continuity of Care Courtesy Education & Information Emotional Support Overall Coordination Pharmac

y

Mailed Pharmac

y Pickup 

Preferences Specialist 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 79.4 79.5 94.7 73.1 83.1 76.5 82.2 66.2 81.3 82 84.9 

Outpatient 

Clinics 83.4 68.9 96.8 71.6 85.2 75.6 78.8 75.1 81.7 78 87.5 

Jackson, MS 

VA Medical Center 1st Quarter FY2006 

The medical center formed a work group to analyze the SHEP results and developed 

action plans for improvements. The Medical Center identified several areas of 

improvement in inpatient and outpatient settings to improve continuity of care, education 

and information, transition, pharmacy pickup, overall coordination, and emotional

support. The action plans included the following actions. 

VA Office of Inspector General 11 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

• Additional positions for a hospitalist, patient advocate, and nursing 

supervisor position to assist with low score areas of SHEP. 

• A position was created for an inpatient ambassador, in which the 

ambassador visits patients/family to discuss concerns and assist with problem

solving in a timely manner. 

• Senior managers provide customer service awards to staff members who go 

over and beyond job requirements to ensure that patient satisfaction is provided. 

• The medical center implemented changes in new employee orientation 

which includes lunch with senior managers and training by the patient advocate to 

ensure that all employees are acting as an advocate for patient care. 

• The facility has incorporated a patient education resource in their high 

volume patient areas and the pharmacy; they also plan to open one in the near 

future in the atrium lobby area.

Senior managers have made and continue to strive to meet patients’ needs and address 

their concerns. 

VA Office of Inspector General 12 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

Appendix A 

Director Comments 

Department of 

Veterans Affairs Memorandum

Date: July 19, 2006

From: Network Director, SCVAHCN (10N16) 

Subject: Combined Assessment Program Review of the G.V. (Sonny) 

Montgomery VA Medical Center, Jackson, Mississippi

To: Marisa Casado, Director, St. Petersburg Office of Healthcare 

Inspections (54SP)

Margaret Seleski, Director, Management Review Service (10B5) 

Director’s Comments 

to Office of Inspector General’s Report 

The following Director’s comments are submitted in response 

to the recommendation and suggestions in the Office of 

Inspector General’s Report: 

OIG Recommendation(s)

Recommended Improvement Actions 1. The VISN Director 

should ensure that the Medical Center Director requires that: (a) 

appropriate measures are taken to ensure the safety of 

psychiatric patients until bathrooms are renovated to correct 

improperly draining showers, (b) ILSM-mandated fire drills are 

separately identified and reviewed by the EOC Committee, and 

(c) the AEMS/MERS system remains the primary information 

and reporting management tool for tracking EOC work orders 

until it is officially replaced. 

Response to 1(a): Appropriate measures are taken to ensure the 

safety of psychiatric patients until bathrooms are renovated to 

correct improperly draining showers. 

VA Office of Inspector General 13 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

Concur Target Completion Date: 7/31/06 

Planned Action: Although a project has been submitted to 

renovate the ward and abate the shower drainage issues, 

immediate actions have been taken to procure non-skid mats 

that will be changed out daily. The new mats should be in 

place by 7/31/06. 

Response to 1(b): ILSM-mandated fire drills are separately 

identified and reviewed by the EOC Committee. 

Concur Target Completion Date: July 2006 

VAMC Jackson will revise the reporting matrix in III.B of the 

EOC minutes to add columns descriptive of ILSM applicability

and estimated project duration. 

Project 

Description Status/Comments 

ILSM Criteria In 

Effect Duration 

 * 

 Denotes criteria in effect: extra drills, walkthroughs, ICRA’s, etc. 

VAMC Jackson will revise the fire drill reporting matrix in VIII 

of the EOC minutes to include columns descriptive of ILSM – 

related conditions and associated project. 

DATE SHIFT LOCATION DEVICE RESPONSE ILSM 

Required Y/N 

& Associated

Project 

PROBLEM 

/CRITIQUE 

VAMC Jackson will expand discussion in section VIII of the 

EOC minutes to detail any ILSM conditions within any 

construction area of the medical center.

----------------------------------------------------------------------------------------- 

VA Office of Inspector General 14 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

Recommended Improvement Actions 2. We recommended 

that the VISN Director ensure that the Medical Center Director

takes action to: (a) ensure all 30-day mortalities and major 

morbidities associated with surgical procedures undergo peer 

review, (b) comply with patient safety goals to ensure correct 

surgery guidelines are followed for invasive procedures outside 

the OR setting, and (c) comply with VHA Handbook 1400.1 to

ensure surgical resident supervision is properly documented. 

Concur See below for target completion dates. 

Response to 2(a): Ensure all 30-day mortalities and major 

morbidities associated with surgical procedures undergo peer 

review. Target Completion Date: Complete May 2006:

Monitoring is ongoing.

Planned Action: The cause of the discrepancy was determined 

to be due to the method utilized to pull surgical deaths. A 

canned report existed in the surgical package that Quality 

Management (QM) was unaware of. Immediately upon being 

made aware of the report, QM staff obtained access and began 

utilizing it to ensure that all deaths within 30 days of any

procedure including tracheotomies will be peer reviewed. 

Response to 2(b): Comply with patient safety goals to ensure 

correct surgery guidelines are followed for invasive procedures 

outside the OR setting 

Planned Action: Areas performing procedures outside the OR 

submit a list of procedures to be performed daily to QM. QM 

reviews procedures for appropriate documentation in the 

medical record and randomly observes the timeout procedure to 

ensure the process is done appropriately. Currently, leadership 

is evaluating further actions to increase compliance. Ongoing 

monitoring is in place. Current compliance for period of 

5/16/06 to 6/17/06 is 91%. Target Completion Date: Target 

met for time period stated above. Monitoring and continuous 

improvement efforts are ongoing. 

VA Office of Inspector General 15 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

Response to 2(c): Comply with VHA Handbook 1400.1 to 

ensure surgical resident supervision is properly documented. 

Planned Action: Concurrent chart reviews are being 

conducted to ensure that documentation is completed as 

required. Providers are contacted by chart reviewers if 

deficiencies are noted that can be corrected timely. Deficiencies

not corrected within required timelines are reported to the 

Director at morning report. The Director meets with individual 

providers as appropriate. 

Compliance rates are as follows: 

May: 95% June: 96% 

Complete May 2006: Monitoring is ongoing. 

----------------------------------------------------------------------------------------- 

Recommended Improvement Actions 3. We recommend that

the VISN Director ensure that the Medical Center Director

takes action to (a) implement a process for communication of 

suspicious or abnormal mammography reports to patients and 

from off-site affiliates as required in VHA Handbook 1104.1 

and (b) document patient notification of mammography and 

biopsy results in medical records. 

Concur Target Completion Date: See Below 

Response to 3(a): Implement a process for communication of 

suspicious or abnormal mammography reports to patients and 

from off-site affiliates as required in VHA Handbook 1104.1 

Planned Action: Complete Prior to the IG visit, the medical 

center had completed a time study on the mammography 

process. As a result of that study, an additional FTE was added 

as a Mammography Program Coordinator (MPC). The 

mammography program coordinator tracks the turnaround time 

for all mammography procedures including breast biopsies. 

The off-site affiliate faxes the radiology reports to MPC within 

72 hours of procedure date. The MPC scans and codes the 

reports into Vista Imaging within 24 hours of receipt (or on the 

same day for Bi Rad 4 and 5 results). Bi Rad reports 3-5 are 

coded as an abnormality which sends an alert to the provider. 

VA Office of Inspector General 16 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

The MPC enters a CPRS note regarding the abnormality and 

notifies the provider by phone with results. 

The MPC sends a patient notification letter for all abnormal and 

normal reports. The patient is notified of abnormal results, via 

certified mail, within five business days of mammogram 

procedure, and of negative results, via regular mail, within 30

business days. The provider also attempts to call the patient 

with abnormal results and documents such communication in

CPRS. 

Response to 3(b): Document patient notification of 

mammography and biopsy results in medical records. 

Planned Action: The MPC sends a patient notification letter 

for all abnormal and normal reports. The patient is notified of 

abnormal results, via certified mail, within five business days of 

mammogram procedure, and of negative results, via regular 

mail, within 30 business days. The provider also attempts to 

call the patient with abnormal results and documents such 

communication in CPRS. 

The MPC has written an amendment to the letter of agreement 

(contract) with off-site affiliate to require mammography 

services be performed in accordance to VHA Handbook

1104.1. Contract is still being negotiated. During the interim, 

the MPC receives a copy of the certified receipt for VA 

documentation of patient notification of abnormal results. 

Negotiations are in progress. 

Target Completion Date: 8/15/06 

----------------------------------------------------------------------------------------- 

Recommended Improvement Action 4. We recommended 

that the VISN Director require the Medical Center Director to 

approve and implement the draft policy requiring the use of the 

VHA-recommended documents and forms for its CNH 

program. 

Concur Target Completion Date: Complete 

VA Office of Inspector General 17 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

Response to 4: Planned Action: Complete The Community 

Nursing Home policy which requires the use of the VHArecommended documents and forms has been approved and 

implemented by the Director. One Nursing Home inspection 

has occurred since the IG visit. The recommended documents 

and forms outlined in the policy were used during this

inspection, and the up-dated information has been entered into 

the website as required. 

(original signed by:)

Robert Lynch, MD

VA Office of Inspector General 18 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

Appendix B 

OIG Contact and Staff Acknowledgments 

OIG Contact Marisa Casado, Director 

Bay Pines Regional Office of Healthcare Inspections 

(727) 395-2416 

Acknowledgments Raymond M. Tuenge 

Charles Cook 

David Griffith 

Annette Robinson 

Triscia Weakley 

VA Office of Inspector General 19 
Combined Assessment Program Review of the G. V. (Sonny) Montgomery VAMC Jackson, MS

Appendix C 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network 16 (10N16) 

Director, G. V. (Sonny) Montgomery VA Medical Center 

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: Thad Cochran, Trent Lott 

U.S. House of Representatives: Charles W. “Chip” Pickering 

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