Department of Veterans Affairs 

Office of Inspector General 

Combined Assessment Program 

Review of the 

Carl T. Hayden VA Medical Center 

Phoenix, Arizona 

Report No. 07-00282-140 June 1, 2007

VA Office of Inspector General 

Washington, DC 20420 
Office of Inspector General 

Combined Assessment Program Reviews 

Combined Assessment Program (CAP) reviews are part of the Office of Inspector 

General's (OIG's) efforts to ensure that high quality health care 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 and benefits 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 Carl T. Hayden VA Medical Center, Phoenix, AZ 

Contents 

Page 

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

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

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

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

Follow-Up on Prior Combined Assessment Program Review Recommendations ......... 2

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

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

Diabetes and Atypical Antipsychotic Medications...................................................... 3

Other Observations .......................................................................................................... 6

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

Cardiac Catheterization Laboratory Standards ............................................................ 7 

Community Based Outpatient Clinics.......................................................................... 7

Contract Community Nursing Home Program ............................................................ 8

Environment of Care .................................................................................................... 9

Quality Management.................................................................................................... 9 

Survey of Healthcare Experiences of Patients ............................................................. 9

Appendixes 

A. VISN Director’s Comments...................................................................................... 11

B. Medical Center Director’s Comments ...................................................................... 12

C. OIG Contact and Staff Acknowledgments................................................................ 16

D. Report Distribution ................................................................................................... 17

VA Office of Inspector General 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

Executive Summary 

Introduction 

During the week of November 13–17, 2006, the Office of Inspector General (OIG) 

conducted a Combined Assessment Program (CAP) review of the Carl T. Hayden VA 

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

operations, focusing on patient care administration and quality management (QM). 

During the review, we also provided fraud and integrity awareness training to 

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

Service Network (VISN) 18. 

Results of Review 

The CAP review focused on eight operational areas. The medical center complied with 

selected standards in seven areas. 

• Breast Cancer Management. 

• Cardiac Catheterization Laboratory Standards. 

• Community Based Outpatient Clinics (CBOCs). 

• Contract Community Nursing Home (CNH) Program. 

• Environment of Care (EOC). 

• QM. 

• Survey of Healthcare Experiences of Patients (SHEP). 

We identified one area that needed additional management attention. To improve 

operations, we made the following recommendations: 

• Diabetes and Atypical Antipsychotic Medications – Improve interventions and 

education for weight control management, document diabetes risk factors, monitor 

and provide intervention for elevated hemoglobin A1c (HbA1c), and monitor and 

manage blood pressure. 

This report was prepared under the direction of Ms. Linda G. DeLong, Director, Dallas 

Regional Office of Healthcare Inspections (OHI). 

VA Office of Inspector General i 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

Comments 

The VISN 18 and Medical Center Directors agreed with the CAP review findings and 

recommendations and provided acceptable implementation plans. (See Appendixes 

A and B, pages 11–15 for the full text of the Directors’ comments.) We will follow up on 

planned actions until they are completed. 

 (original signed by Dana Moore, Ph.D., 

 Deputy Assistant Inspector General for 

 Healthcare Inspections for:)

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

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General ii 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

Introduction 

Medical Center Profile 

Organization. The medical center is a tertiary care medical center that provides a broad 

range of inpatient and outpatient health care services. Outpatient care is also provided at 

five CBOCs located in Mesa, Sun City, Buckeye, Show Low, and Payson, AZ. The 

medical center is part of VISN 18 and serves a veteran population of about 321,541 in a 

primary service area that includes Maricopa, La Paz, Gila, and Navajo counties in 

Arizona. 

Programs. The medical center has 192 hospital beds and 104 nursing home beds and 

provides medical, surgical, mental health, geriatric, rehabilitation, and diagnostic 

services. The medical center has sharing agreements with Luke Air Force Base, the State 

of Arizona, Phoenix Memorial Hospital, and the Shriner’s Childrens Hospital. 

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

Arizona School of Medicine and six other universities to support 75 medical resident 

positions in medicine, surgery, and psychiatry. In fiscal year (FY) 2005, the medical 

center research program had 98 projects and a budget of $1.46 million. Important areas 

of research include diabetes, gastroenterology, podiatry, and cardiology. 

Resources. In FY 2005, medical care expenditures totaled $282 million. The FY 2006 

medical care budget was $261 million. Staffing in FY 2005 was 1,908 full-time 

employee equivalents (FTE), including 142 physician and 382 nursing FTE. 

Workload. In FY 2005, the medical center treated 65,092 unique patients. The medical 

center provided 44,900 inpatient days of care in the hospital and 28,555 inpatient days of 

care in the Nursing Home Care Unit. Inpatient care workload totaled 8,351 discharges 

with an average daily census of 201, including nursing home patients. Outpatient 

workload totaled 582,503 visits. 

Objectives and Scope of the Combined Assessment Program Review 

Objectives. CAP reviews are one element of the OIG’s efforts to ensure that our 

Nation’s veterans receive high quality VA health care services. The objectives of the 

CAP review are to: 

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

patient care and QM. 

• Provide fraud and integrity awareness training to increase employee understanding of 

the potential for program fraud and the requirement to refer suspected criminal 

activity to the OIG. 

VA Office of Inspector General 1 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

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

care administration and QM. Patient care administration is the process of planning and 

delivering patient care. QM is the process of monitoring the quality of care to identify 

and correct harmful and potentially harmful practices and conditions. 

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

and patients; and reviewed clinical records. The review covered the following eight 

programs: 

Breast Cancer Management 

Cardiac Catheterization Laboratory 

Standards 

CBOCs 

CNH Program 

Diabetes and Atypical Antipsychotic 

Medications 

EOC 

QM 

SHEP 

The review covered facility operations for FYs 2005 and 2006 and was done in 

accordance with OIG standard operating procedures for CAP reviews. During this 

review, we also presented fraud and integrity awareness briefings for 312 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. 

Programs needing improvement are discussed in the Opportunities for Improvement 

section (page 3). Recommendations pertain to issues that are significant enough to be 

monitored by the OIG until corrective actions are implemented. 

Follow-Up on Prior Combined Assessment Program Review 

Recommendations 

An analysis of our prior CAP review of the medical center (Combined Assessment 

Program Review of the Carl T. Hayden VA Medical Center, Report Number 04-01456-

181, August 13, 2004) identified no recommendations that required follow-up by 

healthcare inspectors. 

VA Office of Inspector General 2 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

Results of Review 

Opportunities for Improvement 

Diabetes and Atypical Antipsychotic Medications 

Conditions Needing Improvement. 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: (1) intervention and education for weight control (to include diet and 

exercise); (2) documentation of diabetes risk factors in the medical record; (3) monitoring 

and implementation of strategic interventions for elevated HbA1c in patients with 

diabetes; and (4) monitoring of blood pressure on a consistent basis and provision of 

intervention, when elevated. 

Criteria. VHA clinical practice guidelines for the management of diabetes suggests that: 

(a) diabetic patients’ HbA1c, which reflects the average blood glucose level over a period 

of time, should be less than 9 percent to avoid symptoms of hyperglycemia; (b) blood 

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

(c) low density lipoprotein cholesterol (LDL-C) should be less than 120 milligrams per 

deciliter (mg/dL). 

To receive fully satisfactory ratings for these diabetes performance measures, the medical 

center must achieve the following scores: 

• HbA1c greater than 9 percent (poor glycemic control) – 15 percent or lower 

(lower percent is better) 

• Blood pressure less than or equal to 140/90mmHg – 75 percent or higher (higher 

percent is better) 

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

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 and should be performed every 1 to 3 years. A normal FBG is less than or 

equal to 110mg/dL. Patients with FBG values greater than 110mg/dL but less than 

126mg/dL should be counseled about prevention strategies (calorie-restricted diets and 

exercise). A FBG value that is greater than or equal to 126mg/dL on at least two 

occasions is diagnostic for diabetes mellitus. 

Findings. We reviewed a sample of 13 patients who were on one or more atypical 

antipsychotic medications for at least 90 days. Twelve of 13 patients had a body mass 

VA Office of Inspector General 3 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

index with a classification of overweight or obese. Clinical managers could not provide 

medical record documentation to support interventions for weight control management, 

including diet and exercise, for seven patients, three of which had a diagnosis of diabetes 

mellitus. The medical records revealed inconsistencies and lack of documentation of 

diabetes risk factors for 6 of the 13 patients reviewed. Diabetes risk factors include 

components, such as a family history of diabetes, tobacco use, weight status, an abnormal 

glucose tolerance test, and a diagnosis of hypertension. 

Four of the 13 patients had diabetes. All diabetic patients had elevated HbA1c with no 

documented clinical interventions in the medical records. One diabetic patient had the 

last HbA1c, which was elevated, drawn in November of 2004 with no documented 

intervention or follow-up noted in the medical record. However, the patient continues to 

receive health services from the medical center. Immediate contact and appropriate 

intervention with this patient occurred during our inspection. The documentation for all 

four patients also failed to support referrals to the diabetic nurse educator. Medical 

records did not support blood pressure monitoring on a regular basis. Additionally, there 

were no documented attempts to manage elevated blood pressures, as reflected in the 

medical center’s performance measure scores (see graph on next page). 

Diabetic 

patients with 

HbA1c greater 

than 9 percent 

Diabetic 

patients with 

blood pressure 

less than 

140/90mm/Hg

Diabetic 

patients with 

LDL-C less 

than 

120mg/dL

Non-diabetic 

patients 

appropriately 

screened

Non-diabetic 

patients who 

received 

diabetes 

prevention 

counseling 

75 percent 

(3/4) 

50 percent 

(2/4) 

75 percent 

(3/4) 

67 percent 

(6/9) 

33 percent 

(3/9) 

VA Office of Inspector General 4 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

Diabetes Detection and Management

B/P >160/100

Carl T Hayden VAMC Phoenix, AZ

5

8

7

5

6 6

17

0

15

12

9

7

-3

1

5

9

13

17

2005 Qtr 4 2006 Qtr 1 2006 Qtr 2 2006 Qtr 3

Percent

Facility

VISN

National

Better

FY 2005-2006 Performance Measure Scores

Fully 

Satisfactory 

Score = 7

“>” indicates greater than 

“B/P” stands for blood pressure

Recommendation 1. We recommended that the VISN Director ensure that the Medical 

Center Director requires clinicians to improve interventions and education for weight 

control management, document diabetes risk factors, monitor and provide intervention 

for elevated HbA1c, and monitor and manage blood pressure. 

VA Office of Inspector General 5 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

Other Observations 

Breast Cancer Management 

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

screened according to prescribed timeframes. Timely diagnosis, notification, 

interdisciplinary treatment planning, and treatment are essential to early detection, 

appropriate management, and optimal patient outcomes. 

Findings. Mammogram services were offered to patients by 17 fee-basis providers. 

Timely radiology, consultative, and treatment services were provided to patients. When 

indicated, an interdisciplinary treatment plan was developed, and providers promptly 

informed patients of diagnoses and treatment options. 

The performance measures for FY 2005 reflected an overall average of 79 percent, which 

was below the established goal of 85 percent. However, the medical center had taken 

action to improve breast cancer management. At the time of our visit, the FY 2006 

performance measures averaged 84 percent, reflecting considerable improvement. Based 

on our medical record reviews and the facility’s efforts to improve breast cancer 

management, we had no findings. 

Breast Cancer Screening

Carl T. Hayden VAMC

79

75

81

83

85 86

80

76

80 80

77

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%

VA Office of Inspector General 6 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

Cardiac Catheterization Laboratory Standards 

A cardiac catheterization is a special procedure performed in the catheterization 

laboratory to diagnose defects in the heart chambers, valves, and blood vessels. The 

purpose of this review was to determine if the medical center’s cardiac catheterization 

laboratory practices were consistent with the American College of Cardiology and the 

Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document 

on Cardiac Catheterization Laboratory Standards and VHA Handbook 1004.1. These 

standards define requirements for provider procedure volumes, laboratory procedure 

volumes, cardiac surgery resources, QM, the informed consent process, and cardiac 

pulmonary resuscitation (CPR) training. We reviewed these practices and found the 

medical center in compliance with these standards. 

Findings. The medical center’s cardiac catheterization laboratory completed 

515 diagnostic coronary procedures in FY 2005. All of the attending physicians 

privileged in this area performed the procedures without complications and had received 

the required CPR training. The medical center has an ongoing quality improvement 

process that tracks, trends, and analyzes cardiac catheterization procedures to improve 

patient outcomes. In addition, we reviewed 10 medical records of patients who had a 

cardiac catheterization procedure in FY 2005 and found that informed consent 

documentation was appropriately completed. We had no reportable findings or 

recommendations. 

Community Based Outpatient Clinics 

The purpose of this review was to: (1) assess the effectiveness of CBOC operations and 

VHA oversight; (2) determine whether CBOCs are in compliance with selected standards 

of operations (patient safety, QM, credentialing and privileging, emergency plan); and 

(3) determine whether CBOCs improve access, convenience, and timeliness of VA health 

care services. 

VHA Handbook 1006.1 establishes consistent planning criteria and standardized 

expectations for CBOC operations. It defines the CBOC, staffing options, and services 

provided. VHA Directive 2002-074, National Dual Care Policy, establishes a 

system-wide approach to the coordination and provision of medical care that optimizes 

the quality, appropriateness, and efficacy of care and medications provided to eligible 

veterans who are seen by both VA and community providers. VHA Handbook 1100.19, 

Credentialing and Privileging, defines the process for all individuals who are permitted 

by law and the facility to provide patient care services independently. VHA 

Directive 0710, Personnel Suitability and Security Program, establishes requirements to 

perform background checks—or at a minimum a Special Agreement Check—on all 

appointees, health care contractors, and most volunteers prior to their entry on duty at a 

VHA facility. 

VA Office of Inspector General 7 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

Findings. We interviewed key individuals at the parent facility and the CBOC in Mesa, 

AZ. We reviewed documentation and self-assessment tools on descriptions of services 

provided, including warfarin clinic services. We determined that the parent facility 

warfarin clinic, which is directed by a pharmacist, and the CBOC warfarin clinic, which 

is managed by a pharmacist, maintain the same standards and expectations. CBOC 

patients attend an initial education class at the parent facility before they receive their 

first dose of warfarin. CBOC patients’ laboratory tests and follow-up are provided by the 

pharmacist-managed warfarin clinic, with primary care oversight. Patients receive a 

handbook that contains a toll-free telephone number to help facilitate prompt reporting of 

new medications and other vital information. 

The Mesa CBOC EOC inspection demonstrated a clean facility that meets the Joint 

Commission on Accreditation of Healthcare Organizations (JCAHO), Health Insurance 

Portability and Accountability Act, and Life Safety requirements. The emergency 

management plan was current, and clinical staff were educated and knowledgeable about 

rendering emergency care to the veterans. All clinical staff were certified in Basic Life 

Support or Advanced Cardiac Life Support. The emergency response cart was inspected, 

and documentation was up-to-date. An automated external defibrillator was readily 

available to trained staff for use as needed. We had no reportable findings or 

recommendations. 

Contract Community Nursing Home Program 

The purpose of the CNH Program review was to assess VHA facility compliance with 

requirements defined in VHA Handbook 1143.2, Community Nursing Home Procedures, 

regarding the selection, placement, and monitoring of patients in contract CNHs and the 

inclusion of patients and family members in this process. 

Findings. The CNH Program staff provided comprehensive management of the 

contracted nursing facilities and the veterans residing in those facilities. Appropriate 

actions were taken when problems were identified that adversely affected patient safety 

and quality of care. We also determined that patients and family members were involved 

sufficiently in the CNH placement process, provided applicable choices regarding CNH 

selection, and engaged in ongoing communication regarding care. 

The medical center currently has 16 contracted CNHs and 64 veterans residing in those 

facilities. Ten medical record reviews were conducted, and five patients were 

interviewed. Additionally, five nursing facilities were reviewed, and two onsite surveys 

were conducted in order to interview staff and evaluate EOC. The CNH Program 

complied with local and VHA policies. We had no reportable findings or 

recommendations. 

VA Office of Inspector General 8 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

Environment of Care 

The purpose of the evaluation was to determine if the medical center maintained a safe 

and clean health care environment. The medical center must establish a comprehensive 

EOC Program that fully meets all VHA, Occupational Safety and Health Administration, 

and JCAHO standards. To evaluate EOC, we inspected clinical and non-clinical areas for 

cleanliness, safety, infection control, and general maintenance. 

Findings. The medical center maintained an exceptionally clean and safe environment. 

We had no reportable findings or recommendations. 

Quality Management 

The purpose of this review was to evaluate whether the medical center’s QM Program 

provided comprehensive oversight of the quality of care and whether senior managers 

actively supported the program’s activities. We interviewed the medical center Director, 

Chief of Staff, Chief Nurse Executive, and QM personnel. We evaluated plans, policies, 

and other relevant documents. 

Findings. We found that the QM Program was generally effective and provided 

comprehensive oversight of the quality of care in the medical center. Appropriate review 

structures were in place for all program activities reviewed. Generally, when problems 

were identified, actions were taken and adequately evaluated. We found good senior 

management support and clinician participation. We had no reportable findings or 

recommendations. 

Survey of Healthcare Experiences of Patients 

Presidential Executive Order 12862 requires agencies to publish customer service 

standards, survey their respective customers, and use customer feedback information to 

manage the agency. The Executive Career Field Performance Plan for FY 2006 

established that 77 percent of ambulatory care patients and 76 percent of discharged 

inpatients must report overall satisfaction of “Very Good” or “Excellent” in order to meet 

or exceed target goals for satisfaction. 

VA Office of Inspector General 9 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

Findings. The following graphs show the medical center’s SHEP results for inpatients 

and outpatients: 

Carl T. Hayden VA Medical Center 

INPATIENT SHEP RESULTS

 FY 2006 

Quarters 1 and 2 

Access 

Coordination 

of Care 

Courtesy 

Education & 

Information 

Emotional 

Support 

Family 

Involvement 

Physical 

Comfort 

Preferences 

Transition 

National 81.31 78.63 89.95 68.02 65.8 75.85 83.41 74.49 ** 

VISN 81.10 78.30 90.70 67.90 66.80 77.6+ 75.00 72.6+ **

Medical Center 85.1+ 81.3+ 91.9+ 69.30 68.00 78.40 75.50 71.00 **

** Less than 30 respondents 

+ Significantly better than national average 

Carl T. Hayden VA Medical Center

OUTPATIENT SHEP RESULTS

FY 2006 

Quarter 3 

Access 

Continuity of 

Care 

Courtesy 

Education & 

Information 

Emotional 

Support 

Overall 

Coordination 

Pharmacy 

Mailed 

Pharmacy 

Pick-up 

Preferences 

Specialist 

Care 

Visit 

Coordination 

National 80.9 77.00 94.6 72 83 75.1 81.1 64.4 81.3 80.8 84.1 

VISN 78.4 78.40 93.3 70.5 82.8 73.3 79.4 58.2 79.7 78.4 81.4 

Outpatient 

Clinics - 

Overall 

94.6 71.50 87.5 67.5 81.7 66.9 80.5 72.3 76.1 71.9 78.2 

The medical center Director was aware of the SHEP report results for the first and second 

quarters of FY 2006, and results had been communicated to the employees. Medical 

center analysis of the survey results identified four areas targeted for improvement. The 

medical center developed action plans based on these results to improve patient access to 

appointments, emotional support, education and information, and pharmacy pick-up 

services. Action plans have been implemented for areas identified as needing 

improvement. We had no reportable findings or recommendations. 

VA Office of Inspector General 10 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

Appendix A 

VISN Director’s Comments 

Department of 

Veterans Affairs Memorandum

Date: January 4, 2007 

From: Network Director, VISN 18 (10N18) 

Subject: CAP Review of the Carl T. Hayden VA Medical 

Center, Phoenix, Arizona

To: Assistant Inspector General for Healthcare Inspections 

THRU: Director, Management Review Service (10B5) 

I concur with the facility response, and all actions are 

completed. See Medical Center Director’s Comments for 

specific actions. For questions, please contact Joan Funckes, 

Executive Assistant to the Network Director, VISN 18 at 

602.222.2692. 

PATRICIA A. MCKLEM 

Network Director 

VA Office of Inspector General 11 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

Appendix B 

Medical Center Director’s Comments 

Department of 

Veterans Affairs Memorandum

Date: December 27, 2006 

From: Medical Center Director, Carl T. Hayden VA Medical 

Center (644/00) 

Subject: CAP Review of the Carl T. Hayden VA Medical 

Center, Phoenix, Arizona

To: VHA Management Review Service (10B5), VA Central 

Office, Washington, DC 

Thru: Network Director, VA Southwest Health Care Network 

(10N18), Mesa, AZ 

1. The recommendations made during the Office of Inspector 

General Combined Assessment Program Review 

conducted November 13–17, 2006, have been reviewed, 

and our comments and implementation plan are noted 

below. All actions have been completed. 

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

that conducted our review. The team, led by Karen Moore 

and including team members Dr. Wilma Reyes, Marilyn 

Walls, and Linda DeLong, was consultative and 

professional and provided excellent feedback to our staff. 

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

QM Program Manager, Quality Management Department 

at 602.277.5551, ext. 6777. 

 (original signed by:)

DONALD F. MOORE, RPh, MBA 

Medical Center Director 

 

VA Office of Inspector General 12 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

Medical Center Director’s Comments 

to Office of Inspector General’s Report 

The following Medical Center Director’s comments are 

submitted in response to the recommendations in the Office 

of Inspector General Report: 

OIG Recommendations

Recommendation 1. We recommended that the VISN 

Director ensure that the Medical Center Director requires 

clinicians to improve interventions and education for weight 

control management, document diabetes risk factors, monitor 

and provide intervention for elevated HbA1c, and monitor 

and manage blood pressure. 

Concur Target Completion Date: Completed 

Provide appropriate intervention and education for weight management: 

• An instruction letter was mailed to 270 veterans who were 

currently prescribed atypical antipsychotic medications. 

Patients are instructed to report to the Mental Health 

Clinic for weights, blood pressure monitoring, and 

laboratory testing required at specific intervals. 

• Monitoring for weight management of veterans with Body 

Mass Index (BMI) greater than 29 was implemented with 

a nutrition consult generated for completion of the VA 

MOVE multifactor assessment. 

• Referrals are available for education by the Diabetes 

Nurse Educators. Class attendance by patients is currently 

tracked through the Patient Education Services. 

VA Office of Inspector General 13 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

Document risk factors for diabetes in the medical record: 

• Beginning November 1, 2006, all Psychiatrists were 

required to begin use of the standardized template in 

CPRS for documentation of diabetic risk factors and 

initial monitoring of metabolic changes associated with 

prescribing an atypical antipsychotic medication. The 

diabetic risk factor documentation on the template 

includes family history of diabetes, weight management, 

glucose testing, lipid and hypertension management, and 

patient education. 

• Additionally, a baseline blood sugar and cholesterol, 

height, weight, and blood pressure are obtained and 

documented on the template during the initial patient visit. 

• Atypical Antipsychotic Order Sets were designed to 

immediately follow the CPRS template. The order sets 

include laboratory tests for fasting blood sugar, fasting 

lipid panel, and HgbA1c. The order sets also 

automatically generate a consult to Nutrition Services for 

Diabetic Education classes, if appropriate. 

• Pharmacy maintains a database of all patients on atypical 

antipsychotic medications. Each month, Pharmacy 

generates a list for Psychiatry Service to monitor the 

documentation of interventions provided for the treatment 

of weight control, diabetes, hypertension, and cholesterol 

in patients prescribed the atypical antipsychotic 

medications. 

Monitor and provide intervention for elevated HbA1c in all 

patients with diabetes who are receiving atypical 

antipsychotic medications: 

• In addition to the automatic order sets that follow the 

CPRS template for documentation previously described, 

an atypical antipsychotic monitoring graph is available to 

all CPRS authorized users in order to monitor HgbA1c 

and intervene as appropriate in the patient’s care and 

treatment. 

VA Office of Inspector General 14 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

• The values graphed include the name of the antipsychotic 

medication, prescription duration, patient weight, glucose, 

HgbA1c, and LDL Cholesterol (both calculated and 

direct). 

And to monitor and manage blood pressure: 

• As stated previously, an instruction letter was mailed to 

270 veterans that were currently prescribed atypical 

antipsychotic medications. New patients will also receive 

the same letter. Patients are instructed to report to the 

Mental Health Clinic for weights, blood pressure 

monitoring, and laboratory testing required at specific 

intervals. 

• Based on the patient’s history, the CPRS provider 

template allows for ongoing evaluation of the patient who 

has a current prescription for ACE-I for control of blood 

pressure. 

• Blood pressures are monitored at each patient visit. 

Significant changes in blood pressure at any visit require 

an evaluation by the psychiatrist in the mental health 

clinic. 

Patient education programs implemented by mental health 

staff have been designed to provide education regarding the 

relationship of the use of atypical antipsychotic medication, 

body weight, diabetes, blood pressure medication 

management, and the importance of ongoing monitoring to 

maintain both emotional and physical health. 

VA Office of Inspector General 15 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Linda G. DeLong, Director 

Dallas Regional Office of Healthcare Inspections 

(214) 253-3331 

Acknowledgments Karen Moore, Associate Director 

Shirley Carlile 

Roxanna Osegueda 

Wilma Reyes 

Marilyn Walls 

VA Office of Inspector General 16 
Combined Assessment Program Review of the Carl T. Hayden VA Medical Center, Phoenix, AZ 

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network 18 (10N18) 

Director, Carl T. Hayden VA Medical Center (644/00) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction and Veterans Affairs 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction and Veterans Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: 

 Jon Kyl 

 John McCain 

U.S. House of Representatives: 

 Ed Pastor 

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

VA Office of Inspector General 17