JOAN E. CUMMINGS, M.D.
VETERANS INTEGRATED SERVICE NETWORK 12
July 24, 1997
Mr. Chairman, other speakers and guests - Good morning and thank you for this opportunity to discuss the integration of the VA Chicago Health Care System (Lakeside/West Side Divisions).
I would like to state that the Lakeside/West Side VAMC integration is one element of a larger Network strategy aimed at accomplishing five principal goals. These goals are to:
- Reduce Costs: Over the three fiscal years 1997, 1998 and 1999, VISN 12 needs to reduce its annual expenditures by $57 million. According to the VERA methodology, this critical financial target will be achieved by reducing Network expenditures by $8 million in FY '97, $40 million in FY '98, and the remainder in FY '99. As you know, the cost of VA healthcare in Chicago is substantially higher than in most of the rest of the Nation. The goal here is simply to bring VISN 12 into better alignment with VA costs elsewhere. A significant part of the problem in this regard is the over-utilization of VA inpatient care in the Chicago area. I want to stress that costs will be reduced by making our programs more efficient-not by diminishing the quality or amount of care we provide Chicago-area veterans. In fact, we plan to provide better, more accessible care to larger numbers of veterans.
- Increase Access: VA has system wide goals of increasing the accessibility of VA healthcare and of increasing the number of veterans receiving care from VA by 20 percent by 2002. For VISN 12, this goal equates to increasing the number of persons who use VA by approximately 28,000. That is, over the next 5 years, we would like to see the veterans healthcare system providing care for an additional 28,000 veterans in Chicago and other areas of VISN 12. To do this, we need to establish care sites that are much easier to access than the present hospitals. For example, we would like to see that veterans in high-need areas such as Austin on the West Side have much better access to VA by establishing a community-based clinic there. As you know, however, there is not expected to be any new Federal funding to achieve the goal, so if we are going to increase the accessibility of VA healthcare, then we simply have to do so by providing care more efficiently than we have in the past and redirecting the savings to expand access.
- Modernize VA Healthcare: There is a need to modernize both the manner in which veterans healthcare is provided in Chicago, as well as to modernize our facilities. For example, in VISN 12, we need to invest more in fiber-optic infrastructure and computers. Again, given Federal funding realities, progress in this regard can only be achieved by finding savings in other areas. In this regard, I would again note that current state-of-the-art medical practice and new technology is allowing much more care to be provided in outpatient settings than in hospitals and that in recent years healthcare has become primarily an ambulatory activity.
- Optimize Utilization of VA Capital Assets: We need to optimize the utilization of VA physical plan and capital assets to maximize the cost-effectiveness of our services. To do this, we must eliminate unnecessary duplication or redundancy of services and technology, consolidate low-volume specialty services, coordinate resource decisions better, increase Telemedicine usage, and achieve better economies of scale and productivity wherever feasible. For example, one of our Chicago inpatient surgical services has an occupancy rate of about 30%, while the generally accepted standard in health care is that this should be about 85%. Maintaining such low utilization neither uses taxpayer dollars prudently nor promotes quality care.
- Ensure Consistently High Quality Care: Finally, we are trying to ensure that VA provides consistently high quality care throughout the Network (as well as throughout the system). This will require more standardization of our services and better utilization of resources, including the elimination of certain low-volume services, than has occurred in the past.
Mr. Chairman, I would also take this opportunity to reaffirm my belief that both the Lakeside and West Side Divisions are essential and that I, and the Department, have no plan to close either Division. However, if we are going to achieve the five goals: 1. Reduce costs; 2. Increase access; 3. Modernize VA Healthcare; 4. Optimize utilization of VA capital assets; and 5. Ensure consistently high quality care, then there is a need to change how these facilities provide care and what specific services they each provide. I have serious concerns about suggestions that the integration process should be delayed until a complete master plan is available. Because of the decision to administratively integrate the two facilities, many work groups have been established and are planning to implement the goal of a single entity providing primary and tertiary care to the veterans of Chicago. Part of that plan has included reevaluating and assessing all equipment needs and putting them in the context of one VA. For example, there were two angiography suites planned prior to the integration at a cost of $ 2.5 million ($1.25 million per suite-construction and equipment) each. The work group analyzed the patient needs, location, space, etc., and decided to place one suite at West Side and eliminate the second suite. Not only did this save our VISN $1.25 million, because the work group recommendations were able to be implemented immediately we avoided any default on contracts or any unreasonable delay in providing the angiography exams to the patients of Chicago.
There are similar issues facing several other work groups including the ordering of replacement cardiac catheterization equipment. Lakeside has had to suspend cardiac angioplasty procedures in spite of having staff well qualified and highly trained. The work group is again evaluating and is close to a recommendation. Patients for both angiography and cardiac angioplasty require referral to Hines in the interim, which can increase cost.
The two divisions have eliminated 108 positions during our hiring freeze. Many of these vacancies were eliminated either through the buy-out or attrition in expectation of the work groups recommending a smaller number of employees and less supervisors. Not filling for a short period of time has been possible, but if these work groups are not allowed to integrate services between the two divisions for any period of time, this becomes a serious problem.
There is a need for replacement radiologic equipment at VA Chicago. The radiology group has started meeting. If any of their recommendations were delayed this would also preclude the ordering of replacement equipment.
From the time the integration was administratively approved any service chief vacancy which occurred was not filled to allow for the integrated service to function without a loss of leadership. VA Chicago has eight service chief vacancies, some of these have been integrated with a single chief such as Nutrition and Food Service. To fill the others would be difficult if not impossible when applicants would know that an integration was in process. Delaying the integration of a service until all other plans are approved would be very difficult with one of the divisions having no permanent chief or supervisor. An Acting Chief can provide short term coverage but real management requires a permanent Chief.
Lakeside and West Side VA Medical Centers
There are plans in the VISN for another Reduction-In-Force and Staffing Adjustment of Title 38 personnel due to our continued drop in length of stay and movement to more ambulatory care. When this occurs we have been planning to use both divisions and the integrated services will allow us to move employees across the two divisions potentially avoiding some separations.
The Nutrition and Food Service work group has recommended one kitchen to serve both divisions. Delaying the closure of the second kitchen while awaiting the total plan would also delay the savings from the closure of that second kitchen. The anticipated savings from the integration are in our plan for the coming fiscal year. To delay any implementation until the entire plan is available for review by a body unknown, would also force us to look for alternative sources for those savings and may cause a higher number of RIF/Staffing Adjustment requests and may impact on patient care programs directly. At this point with the integration proceeding we would not expect any patient care program closure. We will proceed with following the Integration Coordinating Committee and Stakeholders Advisory Task Group findings and recommendations and thank you for the opportunity to present this overview.
COMPLEMENTARY MISSION AND SERVICES
Lakeside and West Side VA Medical Centers (VAMCs) are both predominantly acute care, highly affiliated, urban medical care facilities. Both opened in 1954 and their respective academic affiliations have been in place since then. In addition, the two medical centers serve the same patient service area. They currently share programs and affiliations in nuclear medicine, chaplain support, music therapy, and human resources management.
Lakeside VA Medical Center, located on the near north side of Chicago, offers primary and tertiary care to 460,000 veterans living in Cook County, Illinois and Lake County, Indiana. Lakeside treated 21,476 veterans in FY95 and had more than 6,600 inpatient admissions and 208,000 outpatient visits. It has 350 authorized beds, 1,200 employees, 300 volunteers and a $96 million annual budget.
Lakeside's Adam Benjamin, Jr. VA Outpatient Clinic, located 55 miles southeast of Chicago in Crown Point, Indiana, provides services to veterans (46,700 visits in FY95) in northwest Indiana. Residents and medical students who train at Lakeside rotate through the outpatient clinic as well. Lakeside services Vietnam Veterans Outreach Centers in Chicago Heights, Illinois and Gary, Indiana.
Lakeside is a member of the McGaw Medical Center of Northwestern University, which also includes Children's Memorial Hospital, Evanston Hospital Corporation, Northwestern Memorial Hospital, and the Rehabilitation Institute of Chicago. Northwestern University Medical School is Lakeside's primary affiliation for the training of 102 paid medical residents and fellows. All physician staff have faculty appointments at the affiliate. There are 22 additional affiliation agreements with 16 other institutions covering eight clinical and allied health professions. Lakeside has a diversified research program consisting of 40 VA-funded and 30 non-VA-funded investigators with 175 projects and funding of approximately $5 million.
West Side VA Medical Center, located on the near west side of Chicago, is a 435-bed facility offering primary and tertiary care. West Side primarily serves the veterans of Cook County, Illinois, who number 411,000. West Side treated 24,781 veterans in FY95 and had more than 8,100 inpatient admissions and 280,000 outpatient visits. It has 1,570 employees and a $123 million annual budget.
West Side has three community-based off-station programs: a Veterans Resource Center, a Drug Dependency Treatment Center and the Hyde Park outpatient clinic.
The University of Illinois at Chicago is West Side's primary affiliation for the training of 129 paid medical residents and fellows. Other training programs cover such areas as dentistry, nursing, podiatry, pharmacy and other allied health professions. West Side has a research program of approximately $1.6 million funding 20 medical investigators focusing on such areas as hematology, gastroenterology and, molecular biology.
- Lakeside and West Side VAMCs share similar geographic and patient population areas:
- The commuting distance between Lakeside and West Side is about six miles and can be traversed by car in 10-20 minutes.
- Both facilities are accessible through a variety of public transportation networks.
- Both Lakeside and West Side draw the majority of their patients from Cook County, Illinois -- 67% for Lakeside and 90% for West Side. Another 19% of Lakeside's patients live in Lake County, Indiana, the site of the medical center's satellite outpatient clinic.
- The geographic area comprising the two medical centers and their overlapping patient populations is also the site of several Vietnam Veterans Outreach Centers and additional access points.
NATURAL PATIENT REFERRAL PATTERNS
The proximity of the two facilities has fostered referral pattern that readily flows in both directions:
- Shared patients: 3,500
- Unique patients at Lakeside: 21,476
- Unique patients at West Side: 24,781 (excluding fee basis)
- Due to their proximity (six miles and 10-20 minutes travel time), the integration of Lakeside and West Side VAMCs has been discussed for many years. In 1994, a VHA Management Improvement Task Force, one of several nationally appointed task forces, evaluated potential FTEE savings from VA medical center integrations and consolidations. The task force identified a number of potential integrations sites, including Lakeside and West Side. In March 1995, the Secretary of the Department of Veterans Affairs approved integrating sixteen (16) medical centers into seven (7). Lakeside and West Side were not included on this initial list. Since that time, the Secretary has approved three additional integrations from that list, e.g., East Orange/Lyons, Pittsburgh--Highland Drive/Pittsburgh--University Drive, and Hot Springs/Fort Meade.
- The four Chicago-area VAMCs, under the auspices of the Chicago Network Council, conducted the facility development planning (FDP) process as a single, integrated planning group. Although the plan identified the potential for integration of facilities, the Network Council took no action since the Veterans Integrated Service Network (VISN) structure was being planned nationwide and it was believed that the VISN would be the appropriate body to deal with most of these issues.
- In August 1995, the Chicago Network Council consolidated the Human Resources Management Services of Hines, Lakeside, and West Side. The consolidated Service is located at Edward Hines, Jr. Hospital. Other potential administrative service consolidations were referred to the VISN for further evaluation.
- Since the establishment of the VISN in October 1995, one of the highest priorities has been the review of the VISN tertiary care facilities for the most effective use of resources. Administrative and clinical integration and consolidation issues were discussed starting with initial visits by the VISN Director to each of the eight facilities and meetings with the Deans of the affiliated medical schools. At the employee "town hall" meetings, which were open to all employees (including union representatives), the Network Director discussed the need to review all clinical and administrative programs, identify appropriate efficiencies, including integrations and consolidations, and evaluate the potential for improvements in resource utilization and patient care. The most commonly identified programs were cardiac surgery, angioplasty, and neurosurgery. The Lakeside and West Side meetings were held in January of 1996.
- Between November 1995 and May 1996, teams to evaluate Pathology and Laboratory Medicine, Imaging, and the development of a single Business Office for the VISN were established. The Communication Team has already implemented a computer network linking all eight of the VISN Medical Centers and is making plans for telemedicine and videoconferencing to enhance services at primary care/rural sites.
- Between October 1995 and February 1996, the Network Director met with the Deans of the six medical schools affiliated with the VISN 12 VAMCs. During these meetings, the Network Director discussed the similarities and proximity of the tertiary care facilities, clinical redundancies, and the potential for cross-facility medical residency training. Edward Hines, Jr. Hospital already has multiple affiliations, specifically with Loyola University, University of Illinois at Chicago, and Chicago Medical School.
- Both medical centers are located in the State of Illinois and therefore equally subject to the impact of existing and future state healthcare legislation. (The Adam Benjamin, Jr. VA Outpatient Clinic is located in Indiana).
- Lakeside and West Side share the same U.S. Senators (Paul Simon and Carol Moseley-Braun) and Congresswoman (Cardiss Collins).
- Both facilities share the same labor market. Both are represented by GSEU, Local 73 of SEIU. In addition the nurses at West Side are represented by the Illinois Nurses Association (INA).
- November 6, 1993 Joan E. Cummings, M.D. (Chairman of the Chicago Network Council and Director, Edward Hines, Jr. Hospital) testified to a subcommittee of the House Veterans Affairs Committee about the Network Facility Development Plan then being formulated by Lakeside, West Side, Hines and North Chicago VAMCs and discussed planning options, including program and facility integration among these four Chicago-area VAMCs.
- June 1994 Network Facility Development Plan finalized and forwarded to VHA Headquarters (then VACO).
- August 1995 Human Resources Management Services of Hines, Lakeside and West Side are consolidated.
- October 15, 1995 Position of Director at Hines became vacant. There are immediate and widespread rumors that Lakeside and West Side will be integrated.
- January 22, 1996 Network Director visited Edward Hines, Jr. Hospital and held town hall meeting with employees.
- January 25, 1996 Network Director visited West Side VAMC and held town hall meeting with employees.
- January 25, 1996 Network Director met with the Dean of the College of Medicine of the University of Illinois at Chicago.
- January 30, 1996 Network Director visited Lakeside VAMC and held town hall meeting with employees, including teleconference hookup with employees of the Adam Benjamin, Jr. VA Outpatient Clinic in Crown Point, Indiana.
- January 30, 1996 Network Director met with the Dean of the Northwestern University Medical School.
- February 27, 1996 Network Director visited North Chicago VAMC and held town hall meeting with employees.
- February 27, 1996 Network Director met with the Dean and department chairs of the Chicago Medical School.
- March 28, 1996 Network Director met with the representatives of the Chicago area Veterans Service Organizations and discussed the issues surrounding duplication of services. The Network Director emphasized the VISN position that the special needs of psychiatry and rehabilitation patients preclude closure of any facility. Consolidation of medical/surgical inpatient services between the two Chicago VAMCs was identified as requiring study by the VISN.
- March 29, 1996 Network Director met with a group comprising the Dean or his representative from five of the six medical schools affiliated with VISN VAMCs (the Dean from the University of Wisconsin was unable to attend). The issue of medical/surgical inpatient services in Chicago was reviewed at length, including discussion of closure of beds at either Lakeside or West Side and increased use of the beds at Hines. The group discussed the creation of a Committee, whose members would have no links to Lakeside or West Side, to assess and make recommendations to the Network Director regarding the placement of the medical/surgical inpatient services.
- April 1, 1996 Network Director met with the staff of the Chicago area Congressional delegation. The clinical redundancies, as discussed with the Veterans Service Organizations, were presented, including the proposed evaluation of the placement of acute medicine and surgery inpatient services.
- April 7, 1996 The position of Director at West Side became vacant with the transfer of John DeNardo to the position of Director of Edward Hines, Jr. Hospital.
- April 16, 1996 Network Director briefed Secretary Brown and his staff on discussions concerning the potential for an integration of Lakeside and West Side in preparation for the Secretary's meeting with Congresswoman Cardiss Collins and Dr. Gerald Moss, Dean of the College of Medicine of the University of Illinois at Chicago.
- April 17, 1996 A newspaper for the faculty, staff, and students of the University of Illinois published an article opposing consideration of facility integration.
- April 24, 1996 Network Director held a second meeting with Dean Moss, University of Illinois, and discussed integration issues, particularly the integration of Lakeside and West Side and the concept of multiple medical school affiliations.
- May 8, 1996 An article regarding the possible integration of Lakeside and West Side appeared in the Business Section of the Chicago Tribune.
- May 13, 1996 Network Director had a discussion with Dr. Harry N. Beaty, Dean of Northwestern regarding the potential for integration. The University is very concerned regarding the maintenance of training programs with VA and wishes to work with the VISN on the implementation of any plans for integration. Dr. Cummings stated her appreciation of the University's position and assured him that they would be full partners in the process.
- May 13, 1996 Letters were sent to the Unions by the Director of Lakeside and the Acting Director of West Side informing them of the potential for integration.
- May 13, 1996 Network Director sent letters to the stakeholders such as VSOs, Congressional delegation members and affiliated medical schools informing them of the planning for a possible integration of Lakeside and West Side VAMCs.
- June 27, 1996 Secretary of Veterans Affairs Jesse Brown announced his decision to integrate the Lakeside and West Side VAMCs under a single management structure.
- September 12, 1996 Network Director met with James A. Balcer, Director/Community Liaison, City of Chicago to provide the Mayor's Office with an overview of the integration.
- September 26, 1996 Network Director met with members of the Minority Veterans Steering Committee and the Montford Point Marine Association to provide them with an update on the integration.
- October 28, 1996 First meeting of the VA Chicago Health Care System Integration Coordinating Committee chaired by Dr. Christopher Terrence, Chief of Staff, VA New Jersey Health Care System. Subsequent meetings have taken place on December 1, 1996, January 29, 1997, March 5, 1997, April 23, 1997, June 4, 1997, and scheduled for July 16, 1997.
- October 28, 1996 First meeting of the VA Chicago Health Care System Stakeholders Advisory Group, chaired by George Cramer, Assistant Director, Illinois Department of Veterans Affairs. Subsequent meetings have taken place on December 4, 1996, February 20, 1997, May 7, 1997, and scheduled for July 30, 1997.
Prior to the implementation of the VISNs in late 1995, the Chicago area VA facilities operated with a Network Council. A representative of the Veterans Service Organizations and the affiliate Deans as well as the VBA Regional Office Director were members of the Council. The management teams of these facilities recognized that, because of their geographic locations, planning needed to be done as a unit. The Chicago Network Council worked to develop a Veterans Health Administration (VHA) health care plan for the four VA facilities in the Chicago area: Hines, Lakeside, North Chicago, and West Side. The goal was a health system that would enhance service to veterans while minimizing the costs and inefficiencies inherent in operating four hospitals with similar missions in close proximity. To this end they adopted several assumptions which remain relevant in the current VISN. These assumptions include:
- All patients are Network patients and are not identified as patients of a specific facility, but identified by physician providers.
- All resources flow through the Network including resident allocation.
- Primary care sites are the entry points for the Network. New Network participants are possible.
- Facilities will be developed to meet the Network integration strategy.
- These issues will be continually discussed with stakeholders in the months to come.
- Discussions will be occurring against the backdrop of the current negotiations over balancing the Federal budget as well as the wide-ranging debate over the future of the nation's health care system and how VA would fit into a reformed health care delivery system. Although the focus of the health care debate has shifted somewhat to the states since 1994, its impact on the importance of facility and/or service integration remains high.
Stakeholders will continue to be apprised of developments concerning the integration process by the Network Director. She has had several telephone conversations with staff members of the Congressional delegation and the news media and will continue to be available as needed. Network staff will continue to respond as rapidly as possible to letters of inquiry and other requests for information.
Veterans Service Officers, Commanders, and Representatives
Ongoing dialogue about service integration will continue to take place with representatives of various Veterans Service Organizations during each facility's regularly scheduled meetings. The Network Director will also continue to have frequent communication with these important stakeholders. The following organizations will be included in this dialogue:
- The American Legion
- Disabled American Veterans
- Jewish War Veterans
- Military Order of the Purple Heart
- Paralyzed Veterans of America
- Veterans of Foreign Wars
- Vietnam Veterans of America
- Montford Point Marine Association
- Minority Veterans Affairs Steering Committee
The Network Director will continue to keep all Congressional representatives involved in and apprised of the integration discussions.
A key factor in any plan to integrate services is the impact on staffs at both Lakeside and West Side. Management will continue to keep employees informed of ongoing developments through staff meetings, newsletters, and other forums.
The GSEU, Local 73 of Service Employees International Union (SEIU) represents employees at both facilities. The Illinois Nursing Association (INA) also represents nursing personnel at West Side. The unions will continue to be informed about integration discussions.
Medical School Affiliates
Northwestern University Medical School and the University of Illinois at Chicago College of Medicine, will continue to be involved in and apprised of discussions concerning integration.
CURRENT STATUS AND ISSUES
1) Integration of
- medical inpatient services,
- surgical inpatient services,
- ambulatory care and access points,
- physical medicine and rehabilitation services,
- mental health services,
- pathology and laboratory medicine,
- information resources management, and
2) The University of Illinois has voiced strong opposition to the consideration of integration of these two facilities.
3) Northwestern University is equally concerned but wishes to work with the VISN staff to effect necessary program changes.
4) The June 27, 1996 announcement by VHA Headquarters to integrate the Lakeside VAMC and West Side VAMC initiated the process to establish an Integration Coordinating Committee to oversee and coordinate:
- developing a single management team,
- developing a unified mission and vision,
- developing recommendations for reducing unnecessary service duplication,
- fostering maximum cost effectiveness, quality, consolidation and satisfaction,
- integrating Decentralized Hospital Computer Program (DHCP) databases,
- developing an organizational chart.
EVALUATING AND MONITORING THE PLAN
An evaluation and monitoring plan will include:
- customer service
- resources utilization
- quality of care
REPORTS AND RECOMMENDATIONS FROM THE INTEGRATION COORDINATING COMMITTEE (ICC)
· Reviewed reports and recommendations from 7 of 14 ICC-chartered work groups for the following services and submitted recommendations and comments to the VA Chicago Health Care System (VACHS) Director: (Bolded Italics=recommendations approved by VACHCS Director and being implemented or awaiting additional approval. Portions of some reports/recommendations have been remanded to work groups for further information and analysis. Italics=report/recommendations submitted to VACHS Director and for review by ICC and STAG).
-information resources mgmt. -nuclear medicine -ambulatory care
-nutrition & food -neurology -medicine
-pathology & laboratory -physical medicine & rehab -psychiatry
-diagnostic radiology -research -surgery
-anesthesiology -therapeutic radiology
· Reviewed reports and recommendations from 12 of 18 integration work groups for the following services and submitted recommendations and comments to the VACHCS Director: (Bolded Italics=recommendations approved by VACHCS Director and being implemented or awaiting additional approval. Portions of some reports/recommendations have been remanded to work groups for further information and analysis. Italics=report/recommendations submitted to VACHS Director and for review by ICC and STAG).
-audiology & speech pathology -fiscal/MCCR (cost recovery) -police & security
-chaplain -hospital based primary care -prosthetics
-dental -library -psychology
-education -medical administration -recreat'l therapy
-engineering -nursing -social work
-environmental mgmt. -pharmacy -voluntary
· Recommended a VA Chicago Health Care System integration goal statement (approved)
· Recommended a VA Chicago Health Care System mission (approved)
· Endorsed consolidation of several administrative and clinical services, including audiology and speech pathology, chaplain, dental environmental management, hospital based primary care, information resources management (approved), neurology, nuclear medicine, nutrition and food services (approved), pharmacy (approved), police and security services, prosthetics and voluntary (approved) services.
· Recommended angiography equipment replacement at West Side and cardiac catheterization equipment replacement at Lakeside (both approved)
· Recommended integration of pathology and laboratory medicine services
· Recommended integration of ambulatory care services at the two divisions, including satellite outpatient clinic sites (Crown Point, Indiana, and 63rd and Stony Island, Chicago).
INTEGRATION IMPLEMENTATION ACTIVITIES RECOMMENDATIONS FROM THE STAKEHOLDERS ADVISORY GROUP (STAG)
- Single director (vs. two facility directors previously), VACHS.
- Merged Lakeside and West Side divisions clinical and administrative computer databases (DHCP-Decentralized Hospital Computer Program) into a single VA Chicago Health Care System computer database
- Consolidated medical care cost recovery section staff of Fiscal Service at West Side Division
- Consolidated payroll section staff of Fiscal Service at Lakeside Division
- Appointed single Chief, Information Resources Management Service for both divisions
- Appointed single Chief, Pharmacy Service for both divisions
- Appointed single Chief, Recreation Therapy Service for both divisions
- Appointed single Chief, Voluntary Service for both divisions
- Appointed one Information Systems Security Officer for both divisions
- Appointed two Decision Support System persons for both divisions
- Estimated cost savings identified to date in VACHS Director-approved work group reports: $691,000 (13.8 FTE)