Fiscal Year 2005 Performance and Accountability Report Published November 15, 2005
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Quality of care is the primary health care focus of both the Veterans Health Administration (VHA) and OIG. Veterans should receive medical care that meets the highest standards. OIG believes that improvements in the measurement and effective use of medical outcome data will provide opportunities for VHA to improve the health care provided to veterans. We will work with VHA to develop appropriate medical outcome measures consistent with industry and Government standards that demonstrate the quality of health care VA provides.
VA provides health care through fee-basis services, scarce medical sharing agreements, contract care, and other arrangements in addition to full-time and part-time VA physician employees. OIG will continue to monitor the development of VA's staffing models for hiring or purchasing physician services to ensure VA physicians provide the full tour of duty and range of services funded by taxpayer dollars.
Providing safe, accessible, high-quality, and timely medical care is just one of the fundamental service delivery issues presenting challenges to VA on a continuing basis. Meeting these challenges requires vigilant management and evaluative oversight. VHA must maintain a fully functional quality management program that ensures high-quality patient care and safety, and safeguards against the occurrence of adverse events.
This area continues to be a management challenge. Our April 2003 report, Audit of VHA's Part-Time Physician Time and Attendance (Report No. 02-01339-85), identified VA physicians who were not present during their scheduled tours of duty, were not providing VA the services obligated by their employment agreement, or were "moonlighting" on VA time. We concluded that VA medical center (VAMC) managers did not ensure that part-time physicians met employment obligations required by their VA appointments. Over 2 years later, 5 of 12 recommendations from our 2003 report to improve physician timekeeping remain unimplemented.
Additionally, our Combined Assessment Program (CAP) (1) reviews have assessed physician time and attendance issues at about 70 facilities nationwide and identified deficiencies at over 30. Our CAP reviews conducted at VHA facilities in 2004, and so far in 2005, continue to identify systemic weaknesses associated with controls over physicians' time and attendance, and the reviews show that some part-time physicians are not fully meeting their VA employment obligations.
VA's Program Response to OIG1A:
VA continues exploring and developing ways to best expand flexibility in physician scheduling to more realistically accommodate demands of patient care, education, and research. VHA Directive 2003-1, Time and Attendance for Part-time Physicians, reiterated existing human resources policy and suggested methods of documenting time and attendance and the proper roles for part-time physicians. Since the directive was issued, VHA has explored ways to create a time and attendance system that meets the needs of VA in providing patient care while at the same time allowing flexibility in scheduling for those part-time physicians who need such accommodations. The concept of eliminating core hours for those part-time physicians on alternative work schedules was agreed upon by all relevant organizational elements. The new policy is documented in revisions to VA Handbooks 5005 (Staffing), 5007 (Pay Administration), and 5011 (Hours of Duty and Leave). These revised policies have been submitted to the Office of Human Resources Management for national release, which is expected to occur in October 2005.
Five VA medical centers have been testing the new policies together with supporting software changes to the Enhanced Time & Attendance System. Concurrently, the Employee Education System has developed a training module to assist the field when national implementation of the new policies becomes mandated. A period of 60 to 90 days will be needed after the issuance of the policies to allow installation and debugging of the software at all facilities and completion of necessary training. Once that has been completed, the policies will be mandatory for all VHA facilities.
The absence of staffing standards for physicians and nurses continues to impair VHA's ability to adequately manage medical resources. Public Law 107-135, Department of Veterans Affairs Health Care Program Enhancement Act of 2001, enacted on January 23, 2002, requires VA to establish a policy to ensure that staffing for physicians and nurses at VA medical facilities is adequate to provide veterans appropriate, high-quality care and services. In July 2004, VHA issued a policy (tied to the number of veterans receiving care) that provides standards for physicians and support staff in primary care. VHA is further behind in its process of establishing staffing models for subspecialty medical physicians. After over 2 years, four of five recommendations relating to physician staffing remain unimplemented from our April 2003 part-time physician time and attendance report.
Our August 2004 report, Healthcare Inspection, Evaluation of Nurse Staffing in VHA Facilities (Report No. 03-00079-183), found that managers could have managed their resources better in providing patient care if VHA had developed and implemented consistent staffing methodologies, standards, and data systems. Currently, 11 of 14 recommendations for improvement remain unimplemented. The absence of nurse staffing guidelines impedes management's ability to ensure that the nursing mix on a ward is adequate to meet patient needs. Title I of Public Law 107-135, Department of Veterans Affairs Health Care Programs Enhancement Act of 2001, provides help in the recruitment and retention of nursing staff through a variety of pay and benefit enhancements, and calls for national staffing guidelines to ensure quality of care.
The OIG continues to work with VHA to review their proposed policy due to concerns over compliance with the intent of Public Law 107-135, particularly with respect to national standards for nurse staffing; the length of time VHA projects to establish a complete set of staffing standards; and questions over the need to develop new data systems versus using existing data resources such as Decision Support System in a consistent manner.
VA's Program Response to OIG1B:
Public Law 107-135 provided that the Secretary of Veterans Affairs shall, in consultation with the Under Secretary for Health, establish a nationwide policy on the staffing of Department medical facilities in order to ensure that such facilities have adequate staff to provide veterans with appropriate high-quality health care and services. The policy must take into account the staffing levels and mixture of staff skills required for the range of care and services provided veterans in Department facilities.
VA has developed a proposed policy to meet this requirement. It relates staffing levels and staff mix to patient outcomes and other performance measures. Under this proposed policy, all VHA facilities would be required to develop a written staffing plan for each distinct unit of patient care or health services. The directive's requirements are to be used in conjunction with the requirements of appropriate accrediting bodies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
Currently, there are no information management systems available that would support nationwide standardized staffing plans for health care providers in varied care settings. However, the workload and patient outcome indicators in the staffing plans required under this directive and other related systems will be used to provide the basis for aggregate reviews at the local, network, and national levels. VA's goal is to develop information management strategies that permit analysis of the relationships between staffing numbers, mix, care delivery models, and patient outcomes for multiple points of care. Projects currently underway will be used to develop a standardized evidence-based approach to staffing plans and use such information to provide high-quality patient care in the most efficient manner possible. It is anticipated that systems for the collection and analysis of this information will be developed in phases over a 4-year period and that they will be in place by September 30, 2009.
Although VHA managers are vigorously addressing VA's Quality Management (QM) procedures in an effort to strengthen patients' confidence, issues remain. OIG and GAO reviews in the 1990s found that managers needed to improve efforts for collecting, trending, and analyzing clinical data. During 2003, we conducted QM reviews at 31 VA health care facilities during CAP visits. All the facilities we reviewed had established comprehensive QM programs and performed ongoing reviews and analyses of mandatory areas. While we found improvements in QM programs, our July 2004 summary report, Healthcare Inspection, Evaluation of Quality Management in VHA Facilities Fiscal Year 2003 (Report No. 03-00312-169), found that facility managers need to strengthen QM programs through increased attention to the disclosure of adverse events, the utilization management program, the patient complaints program, and medical record documentation reviews. Senior managers need to strengthen designated employees' data analysis skills, benchmarking, and corrective action identification, implementation, and evaluation across all QM monitors. Currently, of the report's six recommendations, the one to establish a national policy for disclosing adverse events to patients remains unimplemented.
In 2005, we reported QM deficiencies at six VAMCs. We continued to identify problems with disclosure of adverse events, data collection, trending and analyses, and the patient complaints program.
VA's Program Response to OIG1C:
A new national policy on communication of adverse events will be issued in the first quarter of 2006. Within 6 months of its issuance, each facility will issue its own policy based on the national directive.
VHA established a number of programs to provide long-term health care to aging veterans, but the OIG found that serious challenges continue to exist. For example, we completed reviews in December 2002, involving VHA's Community Nursing Home (CNH) Program; in December 2003, involving Homemaker/Home Health Aide (H/HHA) Program; and in May 2004, involving VHA's Community Residential Care (CRC) Program. We identified issues warranting VHA's attention in all three reviews.
While VHA has contracted with CNHs to provide care for aging veterans, it has taken since 1995 to implement standardized monitoring/inspection procedures, as noted in our December 2002 report, Healthcare Inspection, Evaluation of VHA's Contract Community Nursing Home Program (Report No. 02-00972-44). This delay has led to inconsistent oversight by VHA and varying quality of care for veterans residing in CNHs. We made recommendations to clarify and strengthen the VHA CNH oversight process and to reduce the risk of adverse incidents for veterans in CNHs. After almost 3 years, 3 of 11 recommendations for improvement still remain unimplemented. These include recommendations that VHA medical facility managers devote the necessary resources to adequately administer the CNH program; VHA medical facility managers emphasize the need for CNH review teams to access and critically analyze external reports of incidents of patient abuse, neglect, and exploitation, and to increase their efforts to collaborate with state ombudsman officials; and VHA program officials determine how VHA CNH managers and Veterans Benefits Administration (VBA) Fiduciary and Field Examination (F&FE) employees can most effectively complement each other and share information such as medical record competency notes, online survey certification and reporting data, and F&FE reports of adverse conditions to protect the financial interests of veterans receiving health care and VA-derived benefits.
We found VHA's H/HHA program also needed improvements. We issued a summary evaluation in December 2003, Healthcare Inspection - Evaluation of VHA Homemaker and Home Health Aide Program (Report No. 02-00124-48). We inspected the program at 17 VA medical facilities and found that 14 percent of the patients receiving program services in our sample did not meet clinical eligibility requirements. After almost 2 years, two of four recommendations for improvement remain unimplemented, which include conducting thorough initial interdisciplinary patient assessments prior to placement in the program, and ensuring patients receiving H/HHA services meet clinical eligibility requirements.
In our May 2004 report, Healthcare Inspection - VHA's Community Residential Care Program (Report No. 03-00391-138), we found VAMC inspection teams did not consistently inspect their CRC homes. Our report found that VAMC clinicians did not always conduct interdisciplinary assessments, advise CRC caregivers about patients' conditions or special needs, conduct monthly visits as required, or ensure caregivers received appropriate training. Also, VAMC clinicians and VA regional office (VARO) fiduciary activity supervisors had not met at least once a year to discuss services to incompetent veterans. Currently, 4 of 11 recommendations for improvement remain unimplemented.
VA's Program Response to OIG1D:
In the past year, VHA implemented a Geriatrics and Extended Care referral instrument and reporting system to monitor appropriate placements in its Homemaker/Home Health Aide Services (H/HHA) and other long-term care programs. This monitoring of the appropriateness of placements helps provide assurance that resources for those most in need of H/HHA services are used efficiently.
During this past year, VHA has continued its implementation of actions outlined in the revised VHA Handbook 1143.2, "Community Nursing Home (CNH) Oversight," published on June 4, 2004, which addresses the majority of OIG's recommendations concerning the community nursing home program. The release of the CNH Education and CNH Certification Report Web sites in August and September 2005 resolved most of the unimplemented recommendations. The Education Web site provides needed instruction on the process of annual review and monthly visits, while the Certification Web site allows VA to measure the quality of nursing homes under contract. VHA continues its collaborative work with VBA to share medical care information and information concerning reports of adverse conditions to protect the financial interests of veterans receiving health care and VA-derived benefits.
In regard to the remaining recommendations for improvement involving the Community Residential Care (CRC) program, VA implemented 7 of the 11 recommendations with the publication of the CRC Handbook on March 7, 2005. The remaining initiatives require regulatory changes, which are presently being drafted.
The VBA Fiduciary Program continues to require an annual visit with each VHA medical center in the Fiduciary Activity's jurisdiction. The purpose of these meetings is to discuss cross-cutting program issues, gain a better understanding of each other's program functions, and discuss issues of mutual concern.
Since October 2002, at each site visit performed by the Compensation and Pension (C&P) Service, the Fiduciary Program reviewer has confirmed that the station has conducted the required visits and has reported the findings in the site visit report. C&P Service conducts 19 site reviews yearly and will have visited all 57 VA regional offices by the end of September 2005. Site visit findings have confirmed that VHA-Fiduciary Activity visits are occurring and that field examiners are routinely contacting social workers at the VA medical centers on cases of mutual concern. The lines of communication are open between VHA and VBA.
In March 2002, the OIG issued a series of recommendations to improve overall security, inventory, and internal controls over biological, chemical, or radioactive agents at VHA facilities. We performed this review at the request of the VA Secretary following the September 11, 2001, terrorist attacks and the anthrax infiltration in the U.S. Postal System. In the report, Review of Security and Inventory Controls over Selected Biological, Chemical and Radioactive Agents Owned by or Controlled at Department of Veterans Affairs Facilities (Report No. 02-00266-76), we identified that security and physical access controls were needed in research and clinical laboratories and other areas in which high risk or sensitive materials may be used or stored, or where materials such as biological agents, chemicals, gases, and certain radioactive materials were actually in use.
VHA and the Office of Security and Law Enforcement have completed numerous actions, such as issuing research, clinical, and security publications, and constructing a biosecurity training Web site. In addition, VHA provided a certification that all VA medical facilities are in compliance with the policies. We will close this report after VHA develops procedures to forward requests for research articles to facility Freedom of Information Act Officers.
In the March 2004 report, Healthcare Inspection, Survey of Efforts to Safeguard VA Potable and Waste Water Systems (Report No. 03-01743-114), we found varying degrees of effort in conducting water system assessments and security reviews. This survey was accomplished at the request of the Environmental Protection Agency (EPA) to review security over VA potable and waste water systems, and the degree of VA coordination with EPA concerning those systems. No VHA facility reported that it coordinated efforts with EPA. The Under Secretary for Health needs to standardize security requirements for protecting water infrastructures and coordinate efforts with EPA. Currently one of three recommendations to improve security of water systems on VHA properties remains unimplemented.
VA's Program Response to OIG1E:
The Office of Security and Law Enforcement in the Office of Policy, Planning, and Preparedness updated physical security standards that were published in VA Handbook 0730/1, Security and Law Enforcement, Appendix B, on August 20, 2004, that address the issues raised in the OIG recommendation. The handbook provides updated physical security standards for laboratories and handling/storage of hazardous chemicals and materials. These revised standards are being implemented throughout all VHA facilities. The Office of Security and Law Enforcement conducts periodic facility program inspections during which compliance with the updated standards is verified.
In regard to the report, Review of Security and Inventory Controls over Selected Biological, Chemical and Radioactive Agents Owned by or Controlled at Department of Veterans Affairs Facilities (Report No. 02-00266-76), VA expects to publish the revised VHA Handbook 1200.6 in the first quarter of 2006. It details procedures to forward requests for research articles to facility Freedom of Information Act (FOIA) Officers.
VHA anticipates issuing a directive that addresses the remaining recommendation concerning improving the security of water systems on VHA properties by the end of the first quarter of 2006. The directive is based upon the latest guidance from EPA and the Department of Homeland Security.
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