Office of Oversight, Risk and Ethics
Case Study: How Internal Audit Helped VA Leaders Enhance Their Support of Pain Management
The Veteran Opioid Crisis and the Call for Safer Pain Management
In 2012, more than two million Veterans were diagnosed with chronic pain, and one-third of those Veterans were taking opioids for pain management. From 2010 through 2016, the synthetic opioid and heroin overdose rates increased substantially among Veterans enrolled in Veterans Health Administration (VHA) Health Care. To confront the opioid crisis and improve patient safety, VHA needed to improve and enhance their capability to provide evidence-based, non-pharmacological modalities for treating Veterans for chronic pain.
Challenge: An Unfunded Mandate
Legislation helped push the initiative for better Veteran pain management forward. The Comprehensive Addiction and Recovery Act (CARA) from July 22, 2016, (Public Law 114-198) mandated interdisciplinary pain management teams (PMTs) at all VHA facilities. In addition, the May 18, 2017, VHA Pain Management Team Memorandum (VHA PMT Memorandum, VIEWS 7791174) provided guidance to VA medical facilities on implementation of PMTs. The memorandum required all VA medical facilities to establish PMTs that offer specific interdisciplinary pain management services. These PMTs were required to be made up of a group of specific team members, including providers with pain expertise, addiction medicine expertise, and behavioral and rehabilitation medicine disciplines. However, with limited enterprise-level support, such as no overarching VA program office to oversee implementation, no dedicated budget and unclear requirements, the implementation of PMTs was inconsistent across facilities. Some facilities had fully functional PMTs while others did not.
Solution: Internal Audit to Support CARA Act Implementation
In 2019, to assist VA medical facilities meet their mandate to help Veterans avoid opioid addiction and overdose, the Under Secretary for Health charged Internal Audit (IA) to validate VAMC's compliance with the requirements established by the legislation and the VHA PMT Memorandum. In doing so, the National Program Director for Pain Management, VHA would be able to obtain a full view of PMT implementation status in medical facilities nationwide and pinpoint theirgreatest areas of need.
IA created an interdisciplinary PMT Audit Team consisting of healthcare auditors, clinicians and statisticians to conduct the audit. The PMT Audit Team worked with the National Program Director for Pain Management to determine the information needed to evaluate medical facility compliance with legislation requirements and to identify the PMT data from the medical facilities that would be most beneficial to track in a centralized dashboard. With this data, IA created recommendations to establish a way forward so all VA medical facilities that required by CARA to have PMT would have guidance, leadership expectations and the resources required to put their teams in place.
"We worked as a partnership. It was like a temporary detail of a wonderful team of experts to help us identify what our needs are and to do better. They even gave us a ready-made report." - Dr. Friedhelm Sandbrink, National Program Director for Pain Management, Opioid Safety and Prescription Drug Monitoring Program
Benefit: A Clear Picture of Status and Gaps
The PMT Audit Team worked with VA Pain Management leads to lay out and operationalize a plan. Together, the team conducted an audit of existing programs, interviewed current PMT leads to understand their successes and challenges and created a report that outlined what VA medical facility leaders needed to successfully implement PMT uniformly across the country. Using this data, the team developed a dashboard-the first of its kind-that provided a high-level view of PMT implementation status in VA medical facilities.
Result: Funding and Resources for Full PMT Implementation
Thanks to the needs and requirements outlined in IA's Pain Management Team report, all VA medical facilities will receive proper funding and resources to stand up fully functional PMTs.
In April 2021, Assistant Under Secretary for Health for Clinical Services released a memorandum to all Veterans Integrated Service Network (VISN) Directors, "Fiscal Year 2021 Pain Management, Opioid Safety, and the Prescription Drug Monitoring Programs (PMOP-11SPEC20) Field Funding." This memo provided guidance to Network Directors about the release of field funding for VISNs and facilities to enhance access to pain management services and support the Opioid Safety Initiative.
To support CARA-mandated full implementation of the Stepped Care Model for Pain Management including PMTs, the office in the VHA Specialty Care Program Office will provide funding for dedicated staffing at VISNs and facilities to assure oversight, reporting and coordination of pain care and opioid stewardship programs and initiatives.
As of 2020, VA has reduced prescription opioid use by 64% over the past eight years. With the implementation of fully staffed PMTs operating according to guidance provided by, more Veterans will receive the personalized, interdisciplinary care and pain management options that will keep them safe as they manage their pain.
"If you are a program office and you want to help Veterans, you are going to make your work so much more successful by working with Internal Audit. You will not only be able to do things better because of feedback that you are getting, but also, as you roll things out, you get visibility, credibility, you get attention. And you get data points that will help you focus your priorities." - Dr. Friedhelm Sandbrink
Want to learn more about working with us? We can help you navigate whether IA is the right solution for you, or we can point you in the right direction. Email us at: VHA10IAInternalAuditAction@va.gov.
