STEVEN H. BROWN, MD
DIRECTOR, COMPENSATION AND PENSION EXAMINATION PROGRAM
DEPARTMENT OF VETERANS AFFAIRS
VHA COMPENSATION AND PENSION EXAM VARIABILITY
HOUSE VETERANS AFFAIRS' COMMITTEE
SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
October 20, 2005
My name is Steven Brown, MD. I have been the Director of the Compensation and Pension Examination Program, or “CPEP,” since its inception in 2001, when the Under Secretaries for Benefits and Health executed a Memorandum of Agreement, which established, staffed and funded a joint initiative to improve C&P exams. The goal of improving compensation and pension (C&P) exam quality fits “hand in glove” with the goal of reducing variations among the exams conducted by the Veterans Health Administration (VHA). CPEP’s strategy is to reduce variation by continuously improving quality. Our goal is to ensure that VHA provides consistently high quality exams.
CPEP has adopted a pragmatic approach to quality improvement based on reliable and actionable baseline and ongoing performance data, accountability, and prioritization of effort. CPEP has targeted the ten most frequently requested C&P exam types, which account for approximately 67% of all VHA C&P exam requests. These exam types are: General Medical, Joints, Spine, Foot, Skin, Mental Disorders, Post Traumatic Stress Disorder, Audiology, and Eye.
Establishing the Baseline:
CPEP initially developed reliable and valid methodologies for measuring C&P exam quality based on the Veterans Benefits Administration (VBA) Compensation and Pension Service’s examination worksheets and the rating regulations and used these methodologies to measure baseline C&P exam quality.
CPEP data were generated by a structured, standardized quality review process. Our reviewers answered specific questions about each exam. We refer to these specific questions as “quality indicators.” An example quality indicator is: “Does the exam describe noise exposure during military [service]?”
Once an exam had been reviewed we gave it a score, exactly like a test in school. Exams that scored 90% or better were considered to be of “A” quality, just like in school. The more “A’s” the better. CPEP used quality indicators and the idea of “A” quality work to determine the baseline quality of VHA C&P exams.
In the August 2003 Veterans Integrated Service Network (VISN)-level report, CPEP found that the baseline percentage of “A” quality exams for all VISNs was 53.5%, with a range from 46% to 67%. This information was shared with the examining sites and VISNs, as well as VHA and VBA leadership.
In response to these results, CPEP, with the strong support of Senior VHA and VBA leadership, implemented a number of quality improvement initiatives. These initiatives have, over time, contributed to a decrease in variation in VHA C&P examinations and an improvement in quality among exams. I would like to outline for you a number of the initiatives that VHA, CPEP and the examining sites undertook to improve performance.
CPEP began by taking steps to ensure that all sites were provided with the tools necessary for process improvement. All sites conducting C&P exams were required to participate in a “Collaborative Breakthrough Series” in which sites formed teams that were guided through a multi-month quality improvement exercise by subject matter experts and quality improvement coaches. The CPEP program was assisted in this effort by the VHA Quality Scholars program.
Each collaborative project included two 2-day learning sessions separated by a six-month work period. During the first learning session, the teams were taught how to improve the quality of their compensation and pension examinations and how to develop a specific action plan to implement improvements. In the six months between learning sessions, support was provided to participants through monthly conference calls, monthly coaching calls, and an electronic “chat room.” At the final learning session, the teams shared with each other specific strategies
and the results of their efforts via presentations and posters. Collaborative teams improved overall quality scores for each of the top ten exam types and improved overall timeliness.
To help sites strategically organize and prioritize their improvement initiatives, all VHA facilities performing C&P exams were required by Senior Management to submit a Facility Quality Improvement (QI) Plan using a CPEP template based on principles and techniques learned during the Collaborative Breakthrough Series. Plans included mandatory sections regarding implementation of quality monitoring via CPEP quality indicators, clinician orientation and ongoing education, clinician feedback, organizational reporting, and leadership and resource support. Facility QI plans required the approval and signature of the VISN Director, Facility Director, and Chief of Quality Management. CPEP reviewed each plan and provided constructive feedback when appropriate.
To further support the examination sites, CPEP developed and distributed videos and computer-based training to all VHA facilities on the General Medical, Musculoskeletal, Foot, Heart, Diabetes, Skin/Scar, Muscle, and Respiratory exams. CPEP conducted video conferences on topics such as “DeLuca v. Brown” (in which the Court of Appeals for Veterans Claims held that a rating for a musculoskeletal disability must take into consideration, in addition to limitation of motion specified in rating criteria, the degree of additional loss of range of motion due to pain on repetitive use or during flare-ups and that consideration of weakened movement, excess fatigability (or lack of endurance), and incoordination is not limited to cases involving muscle or nerve injury); exam templates; and quality measurement techniques. CPEP conducted face-to-face training sessions for quality improvement teams, clinicians, administrators, and template “super users." We have made these educational tools available to every site that conducts C&P exams. Finally, CPEP coordinated a conference for VBA and VHA on "Improving the C&P Exam Process Together." The purpose of the conference was to promote effective collaboration between VBA and VHA for the purpose of improving compensation and pension examination processes.
CPEP is collaborating with the VHA Office of Information and the VBA Compensation and Pension Service and Office of Field Operations to computerize all 57 VBA C&P examination disability worksheets in order to eliminate errors of omission via structured data entry. As of April 2005, an initial version of each of the 57 automated templates has been installed at all exam facilities.
Finally, VHA leadership has set higher goals for the quality of exams by establishing a performance target in the Network Directors’ performance plans. For FY 2004 and FY 2005, the performance measure targets were: 64% of exams being of “A” quality to be fully successful and 75% to be exceptional. In FY 2006, the proposed targets have been increased to 83% and 86%, respectively.
In support of leadership’s decision to establish performance targets, CPEP developed routine, monthly reports on the quality of C&P examinations, utilizing the same structured quality review process that was developed for the baseline review. This information helped the VISNs and the examining sites by providing immediate feedback on performance. This information is used by the sites to identify specific areas needing improvement so that interventions could be appropriately focused.
The efforts I've just outlined have led to dramatic improvements in the quality of C&P exams. Improvements of VHA C&P exam quality have increased over the last two years. Since CPEP began monthly monitoring in October 2003, the national average performance measure score has improved. The national average percentage of “A” quality exams for all VISNs was at 80% in June 2005, an increase of 32 %.
The positive results noted in this testimony come as the result of a concerted effort at all levels of VA, including clinicians in the field, CPEP staff, and VHA and VBA leadership. Much has been accomplished, and additional gains can be achieved. We look forward to the opportunity to face these challenges.
Mr. Chairman, this concludes my statement. I am now available to answer any questions that you or other members of the Committee may have.