VA and DOD Health Care
First Federal Health Care Center Established, but Implementation Concerns Need to Be Addressed Gao ID: GAO-11-570 July 19, 2011In Process
FHCC officials have made progress implementing provisions of the Executive Agreement's 12 integration areas. For some areas, all provisions have been addressed, including establishing the facility's governance structure and patient priority system. Progress continues to be made in other areas, such as workforce management and personnel and quality assurance. However, as previously reported by GAO, there have been delays implementing the information technology provisions, which present challenges for operating the FHCC as a fully integrated facility. In addition, while some workarounds are in place, the lack of an military treatment facility (MTF) designation that other DOD medical facilities have presents challenges for efficient FHCC operations and results in uncertainty regarding access to preferred drug prices and provider authority to sign medical readiness forms for active duty Navy servicemembers. Although VA and DOD are assessing the provision of care and operations at the FHCC, their plan to report on performance lacks transparency and may not provide a meaningful and accurate measure of success. Specifically, VA and DOD, through FHCC staff, are using 15 integration benchmarks set forth in the Executive Agreement to assess the integration. From these benchmarks, FHCC staff identified 38 corresponding performance measures to assess the integration's success. While FHCC staff plan to report on these performance measures through a reporting tool they developed--a scorecard that calculates a monthly summary score--the tool lacks transparency and may not provide a meaningful indicator of performance. The scorecard does not account for data collection variation, there is no designated target score(s) to indicate successful integration performance, and the scorecard initially contained a calculation error, all of which raise concerns about its ability to provide transparent, meaningful, and accurate information. GAO recommends that DOD seek a legislative change to designate the FHCC as a MTF--a DOD facility providing medical or dental care to eligible individuals, and that VA and DOD direct FHCC leadership to further evaluate its integration performance reporting tool. DOD did not agree with the recommendation regarding the MTF designation, but GAO continues to believe such designation is important. VA and DOD agreed with GAO's recommendation regarding the scorecard reporting tool.
GAO-11-570, VA and DOD Health Care: First Federal Health Care Center Established, but Implementation Concerns Need to Be Addressed
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United States Government Accountability Office:
GAO:
Report to Congressional Committees:
July 2011:
VA and DOD Health Care:
First Federal Health Care Center Established, but Implementation
Concerns Need to Be Addressed:
GAO-11-570:
GAO Highlights:
Highlights of GAO-11-570, a report to congressional committees.
Why GAO Did This Study:
The National Defense Authorization Act (NDAA) for Fiscal Year 2010
authorized the Departments of Veterans Affairs (VA) and Defense (DOD)
to establish a 5-year demonstration project to integrate VA and DOD
medical care into a first-of-its-kind Federal Health Care Center
(FHCC) in North Chicago, Illinois. Expectations for the FHCC are
outlined in an Executive Agreement signed by VA and DOD in April 2010.
The NDAA for Fiscal Year 2010 also directed GAO to annually evaluate
various aspects of the FHCC integration. This report examines
(1) what progress VA and DOD have made implementing the Executive
Agreement to establish and operate the FHCC and (2) what plan, if any,
VA and DOD have to assess FHCC provision of care and operations. GAO
reviewed FHCC documents and conducted visits to the site; interviewed
VA, DOD, and FHCC officials; and reviewed related GAO work.
What GAO Found:
FHCC officials have made progress implementing provisions of the
Executive Agreement‘s 12 integration areas. For some areas, all
provisions have been addressed, including establishing the facility‘s
governance structure and patient priority system. Progress continues
to be made in other areas, such as workforce management and personnel
and quality assurance. However, as previously reported by GAO, there
have been delays implementing the information technology provisions,
which present challenges for operating the FHCC as a fully integrated
facility. In addition, while some workarounds are in place, the lack
of an MTF designation that other DOD medical facilities have presents
challenges for efficient FHCC operations and results in uncertainty
regarding access to preferred drug prices and provider authority to
sign medical readiness forms for active duty Navy servicemembers.
Figure: Photograph of the Federal Health Care Center (FHCC) in North
Chicago, Illinois:
Entrance to the FHCC's ambulatory care center.
Source: GAO.
[End of figure]
Although VA and DOD are assessing the provision of care and operations
at the FHCC, their plan to report on performance lacks transparency
and may not provide a meaningful and accurate measure of success.
Specifically, VA and DOD, through FHCC staff, are using 15 integration
benchmarks set forth in the Executive Agreement to assess the
integration. From these benchmarks, FHCC staff identified 38
corresponding performance measures to assess the integration‘s
success. While FHCC staff plan to report on these performance measures
through a reporting tool they developed”-a scorecard that calculates a
monthly summary score-”the tool lacks transparency and may not provide
a meaningful indicator of performance. The scorecard does not account
for data collection variation, there is no designated target score(s)
to indicate successful integration performance, and the scorecard
initially contained a calculation error, all of which raise concerns
about its ability to provide transparent, meaningful, and accurate
information.
What GAO Recommends:
GAO recommends that DOD seek a legislative change to designate the
FHCC as a military treatment facility (MTF)-”a DOD facility providing
medical or dental care to eligible individuals, and that VA and DOD
direct FHCC leadership to further evaluate its integration performance
reporting tool. DOD did not agree with the recommendation regarding
the MTF designation, but GAO continues to believe such designation is
important. VA and DOD agreed with GAO‘s recommendation regarding the
scorecard reporting tool.
View [hyperlink, http://www.gao.gov/products/GAO-11-570] or key
components. For more information, contact Debra Draper at (202) 512-
7114 or draperd@gao.gov.
[End of section]
Contents:
Letter:
Background:
FHCC Officials Have Made Progress Implementing VA and DOD's Executive
Agreement, but Challenges May Impact Further Implementation Progress:
VA and DOD Use Integration Benchmarks to Assess Provision of Care and
Operations at the FHCC, but the Performance Reporting Plan May Not
Yield Transparent, Meaningful, and Accurate Results:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Comments from the Department of Defense:
Appendix II: Comments from the Department of Veterans Affairs:
Appendix III: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Federal Health Care Center (FHCC) Progress in Implementing
Selected Provisions for the 12 Executive Agreement Integration Areas,
as of May 2011:
Table 2: Federal Health Care Center (FHCC) Integration Benchmark
Characteristics by Focus Area and Time Frame of Establishment:
Table 3: Federal Health Care Center (FHCC) Integration Benchmarks by
Number of Reported Measures:
Figures:
Figure 1: Timeline of Integrating Health Services at North Chicago VA
Medical Center (NCVAMC) and Naval Health Clinic Great Lakes (NHCGL):
Figure 2: Photographs of Newly Constructed or Renovated Areas of the
Federal Health Care Center (FHCC):
Figure 3: Organizational Chart for Federal Health Care Center (FHCC)
Governance Structure:
Figure 4: Variation in Data Collection Frequency for the 38
Performance Measures:
Figure 5: FHCC Performance Scorecard Methodology: Conceptual Model:
Abbreviations:
AHLTA: Armed Forces Health Longitudinal Technology Application:
DOD: Department of Defense:
FHCC: Federal Health Care Center:
IEEE: Institute of Electrical and Electronics Engineers:
IT: information technology:
MTF: military treatment facility:
NCVAMC: North Chicago Veterans Affairs Medical Center:
NDAA: National Defense Authorization Act:
NHCGL: Naval Health Clinic Great Lakes:
VA: Department of Veterans Affairs:
VistA: Veterans Health Information Systems and Technology Architecture:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
July 19, 2011:
Congressional Committees:
The Departments of Veterans Affairs (VA) and Defense (DOD) have been
authorized to exchange health care resources since the 1982 enactment
of the Veterans' Administration and Department of Defense Health
Resources Sharing and Emergency Operations Act.[Footnote 1]
Specifically, VA and DOD are authorized to enter into contracts or
resource-sharing agreements to improve access to, and quality and cost-
effectiveness of, health care provided by the two departments. Since
1982, VA and DOD have entered into a number of resource-sharing
agreements to provide health care services--emergency, specialty,
inpatient, and outpatient care--to VA and DOD beneficiaries,[Footnote
2] reimbursing each other for the cost of such services. Since the
1990s, VA and DOD have expanded their sharing efforts to include
"joint ventures"--sharing agreements that encompass multiple health
care services and result in mutual benefit, shared risk, and joint
operations in specific clinical areas.
As of 2010, there were nine VA and DOD joint ventures throughout the
country, one of which was between the North Chicago VA Medical Center
(NCVAMC) and DOD's Naval Health Clinic Great Lakes (NHCGL), facilities
located near one another in and around North Chicago, Illinois.
[Footnote 3] Since the 1980s, VA and DOD have entered into multiple
agreements to share health care resources between these two
facilities--including integrating their mental health, surgical, and
emergency departments. Most recently, the National Defense
Authorization Act (NDAA) for Fiscal Year 2010 formalized the
partnership by authorizing the establishment of a 5-year demonstration
project, aimed at fully integrating the VA and DOD facilities into a
single integrated health system, the DOD/VA Medical Facility
Demonstration Project, Federal Health Care Center (FHCC).[Footnote 4]
As the first FHCC, this demonstration project is expected to provide
lessons learned for decision makers for any future FHCCs that may be
established based on this model. The partnership was driven, in part,
by recommendations from the Defense Base Closure and Realignment
Commission,[Footnote 5] as well as an effort by VA to identify
opportunities for realigning and upgrading its health care facilities
across the country.[Footnote 6] Among other goals, the integration of
NCVAMC and NHCGL was intended to increase the efficiency of both
facilities by merging staff and resources.
The level of integration involved in this demonstration project is
unprecedented in the history of VA and DOD health care resource
sharing. Specifically, the FHCC--led by officials from both VA and
DOD, specifically the Navy--is unique because it is designed to be the
first fully integrated joint facility, for use by both VA and DOD
beneficiaries, with a single line of governance and a single funding
source. With an integrated workforce of VA and Navy personnel, the
FHCC expects to provide health care services to approximately 118,000
patients per year. This includes the medical and dental services the
FHCC provides annually to approximately 40,000 Navy recruits to ensure
their medical readiness for duty. By providing these health care
services to Navy recruits, the FHCC is charged with maintaining the
"pipeline to the fleet" of new Navy personnel.
The Secretaries of VA and DOD signed an Executive Agreement in April
2010 that outlined the FHCC's structure and included provisions
regarding health care services and operations at the facility.
Beginning October 1, 2010, services previously provided by NCVAMC and
its community based outpatient clinics, and NHCGL and its associated
clinics, were integrated into a first-of-its-kind FHCC.[Footnote 7]
DOD provided $130 million for construction of an ambulatory care
center and associated structures, such as a parking garage and, in
accordance with the NDAA for Fiscal Year 2010, has the option of
transferring the newly constructed properties to VA 5 years after the
Executive Agreement was executed or once specified benchmarks are
completed, whichever occurs first.[Footnote 8] If instead, the
Secretary of VA or DOD decides not to continue the demonstration
project, DOD retains ownership of the properties.
The NDAA for Fiscal Year 2010 requires that we review and assess
annually: the progress made in implementing the agreement signed by VA
and DOD to establish the FHCC, and the effects of the agreement on the
provision of care and operation of the facility.[Footnote 9] In this
first annual report we address the following questions:
1. What progress have VA and DOD made in implementing the Executive
Agreement to establish and operate the North Chicago FHCC?
2. What plan, if any, do VA and DOD have to assess the provision of
care and operations at the North Chicago FHCC?
To determine what progress VA and DOD have made in implementing the
Executive Agreement to establish and operate the North Chicago FHCC,
we examined the 12 integration areas and provisions outlined in the
Executive Agreement, and assessed the FHCC's progress in meeting them.
Specifically, we reviewed VA and DOD documentation of implementation
plans and progress including timelines for integrating the facility,
policies for operation of the FHCC, and plans for integrating the
financial systems.[Footnote 10] We reviewed our earlier work examining
the information technology aspects of the FHCC integration.[Footnote
11] We also interviewed officials at VA, DOD, and the FHCC about the
planning process for, and implementation of, the integration at the
North Chicago site. In addition, to observe the status of integration
efforts, we conducted site visits to the North Chicago site in
September 2010, prior to the official establishment of the FHCC, and
in January 2011, after FHCC officials estimated that several key
aspects of the integration would be complete by that time.
To determine what plan, if any, VA and DOD have to assess the
provision of care and operations at the FHCC, we examined FHCC staff
efforts to measure care and operations in the context of 15
integration benchmarks--specific performance measures for determining
FHCC success--selected by VA and DOD and identified as one of the 12
Executive Agreement integration areas. We did not assess whether the
integration benchmarks are the most appropriate measures of a
successful integration nor did we evaluate the reliability or validity
of the FHCC's performance results. The integration benchmarks are an
established element of the Executive Agreement to which VA and DOD
have formally agreed and FHCC officials have not yet reported a full
cycle of performance data. We reviewed relevant documents that
describe the FHCC's plans for measuring standards of care provided to
patients and for assessing the success of operations for the site. In
addition, we interviewed officials at VA and DOD, including those at
the FHCC, regarding the provision of care and operations, standards
they use to measure and assess them, and plans to evaluate and report
results in these areas.
We conducted this performance audit from August 2010 to July 2011 in
accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our
findings and conclusions based on our audit objectives.
Background:
VA and DOD's history of sharing resources to provide integrated health
care services to their beneficiaries in and around North Chicago has
occurred in three phases. The third phase culminated in the
establishment of the FHCC, which was formalized by an Executive
Agreement signed by the Secretaries of VA and DOD in April 2010. The
FHCC is unique among other VA and DOD sharing relationships in its
level of collaboration, governance structure, and financial model.
History of VA and DOD Integration of Health Services in North Chicago:
The history of VA and DOD integrating health services in North Chicago
can be described in three distinct phases. (See figure 1.) These
phases cover the time period from 2003 to 2011 and include the
official establishment of the FHCC in October 2010.
Figure 1: Timeline of Integrating Health Services at North Chicago VA
Medical Center (NCVAMC) and Naval Health Clinic Great Lakes (NHCGL):
[Refer to PDF for image: timeline]
Phase 1:
October 2003:
NHCGL inpatient mental health services transferred to NCVAMC and local
VA/DOD resource sharing work group established.
December 2004:
NHCGL Blood Donor Processing Center transferred to NCVAMC.
Phase 2:
January 2005:
Construction of new operating rooms, renovation of existing operating
rooms, and expansion of existing emergency department at NCVAMC.
June 2006:
Transfer of inpatient medical, surgical, and pediatric units;
operating rooms; intensive care; and emergency department from NHCGL
to NCVAMC.
Phase 3:
July 2007:
Groundbreaking for surface parking and parking garage for FHCC.
July 2008:
Groundbreaking for construction on ambulatory care center.
May 2009:
FHCC Advisory Board assembled.
October 2009:
National Defense Authorization Act for fiscal year 2010 provides
authority to operate FHCC.
April 2010:
Secretaries of VA and DOD sign Executive Agreement to establish FHCC.
September 2010:
Construction and renovation completed for FHCC.
October 2010:
FHCC officially established.
December 2010-February 2011:
New construction move-in.
Source: GAO.
Note: Prior to the transfer of services depicted in Phase II, the
NHCGL was known as the Naval Hospital Great Lakes.
[End of figure]
* Phase I began in 2003 when VA and DOD began sharing health care
resources between NCVAMC and NHCGL. NHCGL, then known as Naval
Hospital Great Lakes, transferred its inpatient mental health services
to NCVAMC.[Footnote 12] In the same year, VA and DOD formed a working
group to address issues related to sharing resources between the two
sites. In 2004, the NHCGL blood donor processing center was
transferred to NCVAMC.
* Phase II began in 2005 with the $13-million renovation and
modernization of the NCVAMC, including its operating rooms and an
expansion of the emergency department. In 2006, NHCGL's inpatient
medical, surgical, pediatric, and intensive care units, operating
rooms, and emergency department were transferred to NCVAMC. With the
transfer of inpatient services, the naval hospital became a naval
health clinic, since the facility no longer provided inpatient
services.[Footnote 13]
* Phase III began in 2007 when construction began on new parking
areas, followed in 2008 by the groundbreaking for the construction of
a new ambulatory care center. The FHCC Advisory Board was established
in 2009 to help provide guidance for the integration and future
operation of the facility, which was authorized in the NDAA for Fiscal
Year 2010. In October 2010, the former NCVAMC and NHCGL facilities
merged to become the FHCC, following completion of a $130-million DOD-
funded construction project. The FHCC consists of all the services,
buildings, and locations formerly operated by either NCVAMC or NHCGL
including the new 201,000-square-foot ambulatory care center and its
parking lot and garage, a 45,000-square-foot renovation of the NCVAMC,
and various outpatient and recruit clinics formerly operated by either
NCVAMC or NHCGL. (See figure 2 for photographs of newly constructed or
renovated areas of the FHCC.) The ambulatory care center, which is
physically connected to the NCVAMC, houses outpatient services
including pediatrics, women's health, and mental health. In addition,
it has on-site laboratory, radiology, and pharmacy services, enabling
patients to access these ancillary services in the same location as
their outpatient services.[Footnote 14] Phase III continued into 2011
with the move into the new ambulatory care center and the delivery of
patient services there.
Figure 2: Photographs of Newly Constructed or Renovated Areas of the
Federal Health Care Center (FHCC):
[Refer to PDF for image: 4 photographs]
Exterior of the ambulatory care center at the Captain James A. Lovell
Federal Health Care Center (FHCC);
FHCC exam room;
FHCC patient room;
FHCC pediatric exam room.
Source: GAO.
[End of figure]
Executive Agreement:
In April 2010, the Secretaries of VA and DOD signed the Executive
Agreement that established the FHCC. The Executive Agreement defines
the relationship between VA and DOD for establishing and operating the
FHCC, in accordance with the NDAA for Fiscal Year 2010, and contains
provisions in 12 integration areas regarding specific aspects of FHCC
operations. These 12 areas are: (1) governance structure; (2) access
to health care at the FHCC; (3) research; (4) contracting; (5)
information technology (IT); (6) fiscal authority; (7) workforce
management and personnel; (8) quality assurance; (9) contingency
planning; (10) integration benchmarks; (11) property (i.e.,
construction and physical plant management); and (12) reporting
requirements.
Within the 12 areas are provisions describing how the FHCC should be
operated or what VA and DOD will do as part of their efforts to
jointly operate the facility. Some provisions relate to establishing
and operating the FHCC and have designated deadlines, such as
implementing IT strategies. Other provisions do not have specified
deadlines or will not be met until a certain point in the integration,
or are contingent on other conditions being met. For example, a
provision in the reporting requirements integration area calls for a
final report at the end of the 5-year demonstration in 2015. Since the
report is due at the end of the 5-year demonstration period, this
particular provision cannot yet be implemented.
The Executive Agreement also includes 15 integration benchmarks that
VA and DOD plan to use to determine the integration's success.
Assessment of the integration benchmarks throughout the 5-year
demonstration project will help inform whether the FHCC partnership
should continue beyond the demonstration period authorized by the NDAA
for Fiscal Year 2010.
Unique Features of the FHCC:
The FHCC is unique among VA and DOD joint ventures in three key ways.
First, the FHCC's integration of the provision of care and operations
represents the highest level of collaboration among the nine existing
VA and DOD joint ventures. VA and DOD have periodically assessed their
joint venture arrangements to determine the level of collaboration
between partners, which they measure on a continuum from "separate" to
"consolidated." They use this continuum to assess program elements of
a joint venture's partnership such as governance, education and
training, and research. VA and DOD officials reported to us that
overall, the FHCC has more program elements, such as its clinical
services and staffing, which fall on the "consolidated" end of the
collaboration continuum than any of the other joint venture sites.
Second, the FHCC operates under a single line of governance to manage
medical and dental care, and has an integrated workforce of
approximately 3,000 civilian and active duty military employees from
both VA and DOD[Footnote 15]--a feature that is unique to the FHCC.
Although the FHCC's leadership and workforce are integrated, they also
remain directly accountable to both VA and DOD through the Joint
Executive Council and the Health Executive Council.[Footnote 16] VA
and DOD officials told us that none of the other joint venture sites
has an integrated governance structure and instead maintain separate
VA and DOD lines of authority. The third way in which the FHCC is
unique among VA and DOD joint ventures is its financial model. The
FHCC has a single funding source to which VA and DOD will contribute,
unlike the other joint venture sites which have separate VA and DOD
funding sources. The NDAA for Fiscal Year 2010 established the Joint
DOD-VA Medical Facility Demonstration Fund (Joint Fund) as the funding
mechanism for the FHCC, with VA and DOD both making transfers to the
Joint Fund from their respective appropriations.[Footnote 17]
FHCC Officials Have Made Progress Implementing VA and DOD's Executive
Agreement, but Challenges May Impact Further Implementation Progress:
FHCC officials (including both VA and DOD officials) have made
progress implementing the provisions of the 12 Executive Agreement
integration areas. Four of the 12 integration areas have been fully
implemented, 7 are in progress and proceeding according to plan, and 1
area, IT, has been delayed and continues to present challenges. In
addition, the FHCC's lack of a military treatment facility (MTF)
designation has presented challenges for FHCC operations and health
care providers.
FHCC Officials Have Implemented Four Executive Agreement Integration
Areas and Are Progressing on Seven Others, but IT Implementation Has
Been Delayed:
FHCC officials have addressed all provisions for 4 of the 12 Executive
Agreement integration areas, are progressing in their implementation
of 7 other areas, and have experienced delays in the implementation of
1 area, IT. (See table 1.)
Table 1: Federal Health Care Center (FHCC) Progress in Implementing
Selected Provisions for the 12 Executive Agreement Integration Areas,
as of May 2011:
Executive Agreement integration area: Governance structure;
Key provisions: Executive team structure and advisory bodies;
Status: Implemented.
Executive Agreement integration area: Access to health care at the
FHCC;
Key provisions: Patient priority system and eligibility of members of
the uniformed services for care;
Status: Implemented.
Executive Agreement integration area: Research;
Key provisions: Institutional Review Board approval and policy for the
protection of human subjects;
Status: Implemented.
Executive Agreement integration area: Contracting;
Key provisions: VA and DOD responsibility for contracting support;
Status: Implemented.
Executive Agreement integration area: Fiscal authority;
Key provisions: Budgeting, joint funding authority, and reconciliation;
Status: In progress.
Executive Agreement integration area: Workforce management and
personnel;
Key provisions: Staffing, training, and the transfer of DOD civilian
personnel to VA;
Status: In progress.
Executive Agreement integration area: Quality assurance;
Key provisions: Accreditation and oversight from external entities and
credentialing and privileging of health care providers;
Status: In progress.
Executive Agreement integration area: Contingency planning;
Key provisions: Emergency and disaster management and security;
Status: In progress.
Executive Agreement integration area: Integration benchmarks;
Key provisions: Benchmark completion and property transfer before 2015;
Status: In progress.
Executive Agreement integration area: Property;
Key provisions: Construction, transfer of property, and physical plant
management;
Status: In progress.
Executive Agreement integration area: Reporting requirements;
Key provisions: VA and DOD reports to Congress and Comptroller General
reviews;
Status: In progress.
Executive Agreement integration area: Information technology (IT);
Key provisions: Administrative and clinical IT, including efforts to
achieve interoperability between VA and DOD systems;
Status: Delayed.
Source: GAO analysis.
Note: Selected provisions describe new actions, policies, or processes
that will or must be in place for the FHCC, excluding such activities
that were already in place at the separate VA and DOD facilities prior
to the integration.
[End of table]
FHCC Officials Have Fully Implemented Provisions for Four Integration
Areas:
Officials have completed implementation of the governance structure,
access to health care at the FHCC, research, and contracting
integration areas.
Governance structure. The Executive Agreement defined the structure of
the FHCC's governance structure and leadership, with a VA official
serving as the director and a naval captain serving as the deputy
director. (See figure 3.) As of October 1, 2010, the former director
of NCVAMC became the director of the FHCC, and a command change
brought in a new naval captain to become deputy director, taking over
command from the former NHCGL commanding officer.
Figure 3: Organizational Chart for Federal Health Care Center (FHCC)
Governance Structure:
[Refer to PDF for image: Organizational Chart]
Top level:
Joint Executive Council; Health Executive Council (jointly staffed).
Second level, reporting to Joint Executive Council; Health Executive
Council:
FHCC Advisory Board (jointly staffed).
Third level, reporting to FHCC Advisory Board:
FHCC Director (VA staffed);
* FHCC Stakeholders Advisory Council (jointly staffed).
Fourth level, reporting to FHCC Director:
FHCC Deputy Director (DOD staffed).
Fifth level, reporting to FHCC Deputy Director:
Clinical and administrative divisions[A] (jointly staffed).
Chain of Command:
VA to:
Joint Executive Council; Health Executive Council;
FHCC Director.
DOD to:
Joint Executive Council; Health Executive Council;
FHCC Deputy Director.
Source: GAO.
[A] There are six clinical and administrative divisions at the FHCC:
Patient Services, which includes laboratory and radiology services as
well as staff training and education; Dental Services, including oral
surgery and general dentistry; Patient Care, which includes the
Departments of Surgery, Ambulatory Care, and other health care
provided at the facility; Fleet Medicine, which oversees the clinics
providing services to Navy servicemembers; Facility Support, which
includes security and facility management; and Resources, which
oversees financial management and human resources, among other
functions.
[End of figure]
In addition, the advisory bodies described in the Executive Agreement
are in place. The FHCC has an Advisory Board--co-chaired by and
comprised of senior officials from VA and DOD--that monitors the
FHCC's performance and advises on strategic direction, mission,
vision, and policy. The Advisory Board also provides input into the
performance evaluations of FHCC leadership and serves as a
communication link between VA and DOD executive leadership and the
FHCC through the Joint Executive Council and the Health Executive
Council. Also, a Stakeholders Advisory Council--comprised of members
from various regional and local organizations representing FHCC
interests[Footnote 18]--provides feedback on how well the FHCC is
meeting customers' needs and whether the FHCC is meeting VA and DOD
missions. VA and DOD officials also designed the major operational
components of the FHCC to have shared VA and DOD leadership. The six
clinical and administrative divisions[Footnote 19] that report to the
director and deputy director are led by an associate director and an
assistant director, one from VA and the other from the Navy.
Access to health care at the FHCC. To address access to health care at
the FHCC for veterans and DOD beneficiaries, the NDAA for Fiscal Year
2010 and the Executive Agreement established a patient priority system
that is unique to the FHCC for use in the event of resource
constraints. FHCC's patient priority system is based on the priority
list for TRICARE, DOD's program to provide health care to its
beneficiaries, and incorporates VA beneficiaries.[Footnote 20] More
specifically, the system prioritizes active duty servicemembers above
veterans and other DOD beneficiaries as follows:
1. members of the Armed Forces on active duty;
2. veterans and non veteran VA beneficiaries,[Footnote 21] and TRICARE
Prime-enrolled active duty dependents;
3. TRICARE Prime enrolled retirees, their dependents and survivors;
4. TRICARE Standard active duty dependents; and:
5. TRICARE Standard retirees, their dependents, and survivors,
including TRICARE for Life beneficiaries.
Officials told us that they do not anticipate needing to activate the
patient priority system because they are currently meeting the needs
of FHCC beneficiaries--health care providers at the FHCC currently
serve all patients based on medical need. Officials also told us that
their monitoring of Navy recruit medical readiness ensures they are
able to maintain the "pipeline to the fleet" of enlisted sailors.
Research. The Executive Agreement stated that the FHCC would comply
with VA policy for research efforts, but provided that when DOD
researchers or patients are involved in a study, the Navy's rules on
protection of human subjects would apply in addition to VA's. In
addition to implementing this provision, FHCC officials told us they
decided to integrate the research program at the FHCC. Since a
majority of the research conducted is VA research, it was easily
incorporated into the broader FHCC integration efforts. The FHCC has
an Institutional Review Board[Footnote 22]--a body responsible for
reviewing and approving research protocols involving human subjects--
located at a hospital affiliated with the FHCC that provides research
management and operational oversight to the FHCC, the Edward Hines,
Jr. VA Hospital in Hines, Illinois. Also, in accordance with the
Executive Agreement, FHCC officials told us that a DOD Institutional
Review Board in San Diego, California, may also be involved for
research involving DOD researchers or active duty servicemembers at
the FHCC.
Contracting. The Executive Agreement stated that VA would be
responsible for providing contracting support at the FHCC. Similar to
the FHCC's research efforts, officials chose to integrate the
contracting function as part of the broader integration. Five former
Navy civilian employees who were at NHCGL prior to the integration
were converted to VA civilian employees to help support the integrated
contracting and purchasing functions.
FHCC Officials Are Making Progress in Implementing Provisions for
Seven Integration Areas:
Officials' efforts have progressed as planned to implement provisions
for the fiscal authority, workforce management and personnel, quality
assurance, contingency planning, integration benchmarks, property, and
reporting requirements areas.
Fiscal authority. The FHCC fiscal authority integration area included
the development of an integrated budgeting and financial
reconciliation process. For fiscal years 2011 through 2013, the FHCC
plans to use historical financial data to budget and determine the
amount each department will transfer to the Joint Fund and expects to
manually conduct the year-end reconciliation process. Officials told
us that by fiscal year 2014, the FHCC intends to have an automated
year-end financial reconciliation process. However, as of April 1,
2011, the integration area on fiscal authority had not been fully
implemented because appropriations had not been made available for the
Joint Fund. The NDAA for Fiscal Year 2010 established the Joint Fund
as the FHCC's funding source, but FHCC officials could not use it
until funds had been authorized and appropriated for VA and DOD to
transfer into the Joint Fund, which occurred in April 2011.[Footnote
23] Until that time, the FHCC was funded by an alternative funding
mechanism established by the Executive Agreement for use in the event
that Congress did not authorize and appropriate funds to be
transferred to the Joint Fund. As of April 2011, FHCC officials
planned to cease use of the alternative funding mechanism and begin
use of the Joint Fund at the start of the next quarter on July 1, 2011.
The delay in availability of funds may result in a delay in addressing
an NDAA for Fiscal Year 2010 requirement that is also one of the
integration benchmarks--the annual independent audit of the Joint
Fund, which is conducted at the end of the fiscal year. The audit will
evaluate the adequacy of VA's and DOD's proportional contributions to
the Joint Fund.[Footnote 24] In addition, the implementation of the
automated financial reconciliation process is contingent on a related
IT capability, which does not yet have an estimated completion date.
Together, these delays may impact the FHCC's ability to address one of
the measures of its integration's success.
Workforce management and personnel. In the workforce management and
personnel integration area, the NDAA for Fiscal Year 2010 authorized a
transfer from DOD to VA of the positions and personnel necessary to
operate the FHCC.[Footnote 25] The Executive Agreement identified 533
DOD civilian positions that were eligible for transfer to VA, and FHCC
officials told us that VA made offers of employment to the individuals
in those positions. In total, 469 DOD civilian personnel were
transferred to VA as of October 10, 2010--the deadline established in
the Executive Agreement. The 533 converted civilian positions, along
with 724 active duty positions, 1577 VA civilian positions, 249 VA and
DOD contract positions, and 18 new housekeeping positions, comprise
the approximately 3,000 positions that initially staffed the FHCC.
FHCC officials are in the process of resigning affiliation agreements
with health care facilities and training institutions and plan to
address another provision regarding the development of criteria and
assessment methods to measure staff experiences with the integration
at a later date. Officials have also integrated their staff training
through an integrated education department.
Quality assurance. The Executive Agreement stated that the FHCC would
have one integrated quality assurance plan and would maintain
accreditation by the external accrediting bodies required by either VA
or DOD. It also outlined the FHCC's credentialing and privileging
process for health care professionals. FHCC officials have an
integrated quality assurance plan for the facility in place, as well
as policies addressing credentialing and privileging of providers and
the role of independent duty corpsmen at the FHCC.[Footnote 26] While
some bodies, such as the VA Office of the Inspector General, have
conducted reviews of the FHCC since it was established,[Footnote 27]
other accreditation and certification reviews, such as that of The
Joint Commission,[Footnote 28] are pending and the first reviews for
the FHCC will occur on the schedules that were in place for the NHCGL
and NCVAMC prior to the integration.
One component of quality assurance is the maintenance of clinical
skills for the FHCC's Navy health care providers. Officials told us
that one of the benefits of the integration is that dental school
graduates obtaining advanced education in the Navy can see veteran
patients while completing their residencies and have opportunities to
be exposed to different dental conditions than those normally seen in
the generally younger and healthier recruit population. Some of these
dentists will be placed on ships, where they are often the only on-
site dentist. FHCC officials described a similar benefit for health
care professionals providing inpatient care.
Contingency planning. The Executive Agreement included contingency
planning provisions regarding the establishment of certain FHCC
emergency management positions, and stated which antiterrorism and
other security guidelines would inform the establishment of the FHCC's
security plans. In addition, the FHCC must maintain training standards
for staff that meet the joint VA/DOD programs in this integration
area. The FHCC has the necessary emergency management personnel,
training standards, and programs in place; however, officials are in
the process of finalizing an agreement to outline the relationship
between VA police and DOD security personnel.
Integration benchmarks. The Executive Agreement established 15
integration benchmarks to define the degree of the integration's
success. VA and DOD officials at the regional and headquarters levels
and FHCC officials worked together to develop these benchmarks that
cover such topics as patient and staff satisfaction, clinical and
administrative functions, and external evaluation. The integration
benchmarks are being used by the FHCC to assess provision of care and
operations and are discussed in more detail later in this report.
Property. The Executive Agreement and the NDAA for Fiscal Year 2010
describe the terms of the transfer of property ownership that may
occur at the end of the 5-year demonstration period from DOD to VA. A
determination to transfer ownership may occur upon the earlier of (1)
completion of the integration benchmarks or (2) 5 years from the date
the Executive Agreement was executed. If it is determined that the
FHCC should not continue to be an integrated facility, DOD will retain
ownership of the ambulatory care center and associated structures that
were built with DOD funds.
Reporting requirements. There are several reporting requirements
described in the Executive Agreement that were established by the NDAA
for Fiscal Year 2010, including submitting the Executive Agreement to
the appropriate committees of Congress 1 week before its execution,
and a final report from the Secretaries of VA and DOD that will be
submitted 5 ½ years after the Executive Agreement was
executed.[Footnote 29] The report is to describe and assess the
performance of the FHCC, and to provide a recommendation as to whether
the partnership should continue beyond the demonstration period.
Congress will make the final determination as to whether to continue
the partnership.
Implementation of Key IT Integration Area Provisions Has Been Delayed:
The Executive Agreement identified IT capabilities that VA and DOD
were to have in place by the opening day of the FHCC, October 1, 2010,
to facilitate interoperability between VA and DOD electronic health
record systems,[Footnote 30] as well as other capabilities for
financial management and outpatient appointments that are to be
developed in the future. The three capabilities that were to be in
place upon the FHCC's opening were (1) medical single sign-on--which
allows staff to use one screen to access both the VA and DOD
electronic health record systems; (2) single patient registration--
which allows staff to register patients in both systems
simultaneously; and (3) orders portability for laboratory, radiology,
pharmacy, and consults--which will allow VA's and DOD's electronic
health record systems to exchange information for these medical
orders. In addition, the Executive Agreement stated that all IT
capabilities developed for the FHCC will be exportable to other VA/DOD
joint ventures and medical sharing locations.
FHCC officials, working with VA and DOD officials, have implemented or
are in the process of implementing the IT provisions of the Executive
Agreement, including working with a strategic working group that
supports implementation efforts,[Footnote 31] as well as defining
procedures for the reporting of information security incidents.
However, VA and DOD did not meet designated deadlines for the three
capabilities that were to be in place upon opening and, as of May
2011, not all capabilities are fully implemented at the FHCC. Single
sign-on and single patient registration were implemented on December
13, 2010. On March 3, 2011, FHCC officials began limited use of orders
portability for laboratory and radiology. While full operational
capability was expected on April 14, 2011, officials told us that both
orders portability capabilities remained in limited use through April,
with radiology expected to have full operational capability on June 1,
2011, and laboratory delayed until an undetermined date. FHCC
officials decided to delay implementation of these capabilities in
order to allow more time to correct problems, such as difficulty
managing large numbers of automated laboratory test orders, and to
train users on the system. Additionally, FHCC officials told us that
implementation of the remaining orders portability capabilities
(pharmacy and consults) are indefinitely delayed while decisions are
made at the department level regarding development of these
capabilities. FHCC officials have implemented an interim orders
portability process for the pharmacy while VA and DOD continue to
develop the automated orders portability capability. This interim
process necessitated the hiring of five full-time pharmacists to
conduct manual checks of the VA and DOD electronic health record
systems to ensure that the FHCC is able to ensure patients' safety by
identifying possible interactions between drugs prescribed in the two
separate systems.
The three IT capabilities were delayed in part because of a need for
more on-site testing before use, as well as a lack of an integrated
and comprehensive project plan from VA and DOD. During on-site
testing, FHCC officials found that some requirements for pharmacy and
radiology orders portability did not meet the FHCC's needs. FHCC
officials told us that an earlier round of system testing was
performed in an off-site environment that did not effectively simulate
the FHCC environment. In addition, we reported in February 2011 that,
although VA and DOD performed various planning activities for the FHCC
IT system, these activities generally were not completed in accordance
with effective project planning practices including defining the
scope, estimating the cost, and establishing a budget and schedule for
the project.[Footnote 32] Additionally, we expressed concern that VA's
and DOD's ineffective planning jeopardized their ability to fully
provide the IT system capabilities the FHCC needs on a timely basis.
[Footnote 33]
As a result of the need for more on-site testing and the ineffective
project planning, VA and DOD have not yet fully provided clinicians at
the FHCC with the IT capabilities the Executive Agreement identified
as needed upon opening. Further, the IT issues caused a 2-week delay
in the start of the move of clinical services into the new ambulatory
care center. Additionally, since the needed capabilities have not yet
been fully implemented, the departments are not in a position to
export all the planned capabilities to other locations, as provided
for in the Executive Agreement.[Footnote 34]
Lack of MTF Designation Has Presented Challenges for FHCC Operations
and Health Care Providers:
According to DOD policy, an MTF is a military treatment facility owned
and operated by DOD that is established for the purpose of furnishing
medical and/or dental care to eligible individuals. Among other
things, designation as an MTF allows co-payments to be waived for
services received by DOD beneficiaries. The former NHCGL was an MTF,
and FHCC officials will continue to list it as such on DOD's list of
MTFs through the FHCC demonstration period even though the NHCGL no
longer exists.[Footnote 35] The FHCC's ambulatory care center, which
is currently owned by DOD, is the only part of the FHCC that has an
MTF designation. The NDAA for Fiscal Year 2010 provided that the
facility, defined for purposes of the statute as the new Navy
ambulatory care center, parking structure, and supporting structures
and facilities, as well as related medical personal property and
equipment, may be treated as an MTF for purposes of eligibility for
DOD health care.[Footnote 36] However, DOD has concluded that it does
not have the authority to designate the FHCC as an MTF since the FHCC
generally, including those areas of the FHCC that provide inpatient
services, is owned by VA and that its authority to consider the FHCC
an MTF is limited to the purpose of confirming the categories of
beneficiaries eligible for DOD health care.
FHCC officials, working with VA and DOD, have implemented or are in
the process of implementing workarounds for three issues related to
the lack of an MTF designation:
1. Certain DOD beneficiaries would have been responsible for co-
payments for care received at the FHCC.[Footnote 37] DOD beneficiaries
do not have to pay co-payments at MTFs, such as the former NHCGL.
However, because the FHCC lacks the MTF designation, certain DOD
beneficiaries would have had to pay co-payments for services received
at the FHCC. This issue was temporarily resolved through a
demonstration project to waive co-payments for DOD beneficiaries at
the FHCC during the 5 years of the FHCC demonstration.[Footnote 38]
2. The FHCC was unable to continue DOD's personal services
contracts.[Footnote 39] FHCC officials told us that prior to the
integration, the naval facilities used personal service contracts for
temporary health care provider staffing needs, but DOD may only enter
into personal services contracts to fulfill health care needs at MTFs
and in other select circumstances. FHCC officials decided to convert
the personal services contract positions that were needed at the FHCC
into VA civilian employee positions. FHCC officials told us that
personal services contracts are a preferred method for accommodating
fluctuations in medical and dental workload resulting from changes in
the number of Navy recruits on site at any given time, but they
anticipate that the Navy's plan to maintain more consistent recruit
numbers throughout the year will reduce the need for temporary staff.
3. The FHCC's lack of MTF designation resulted in uncertainty about
the FHCC's ability to use DOD's contracted drug prices for
prescription orders, including the extent to which DOD's drug pricing
information could be shared with VA's pharmacy vendor. VA and DOD have
contracts with pharmacy vendors to obtain drugs and with manufacturers
to obtain favorable drug pricing for their beneficiaries, but the two
departments have contracts with different vendors and have different
pricing arrangements with manufacturers. As part of the broader
integration efforts at the FHCC, VA and DOD signed an agreement to use
VA's pharmacy vendor for the FHCC while maintaining access to DOD's
contracted manufacturer prices for DOD beneficiaries treated at the
FHCC. However, FHCC officials told us they were later denied access to
manufacturer pricing arrangements because the FHCC was not an MTF. DOD
officials told us that the TRICARE Management Activity's Pharmacy
Operations Department determined in March 2011 that the FHCC was
entitled to use DOD-contracted prices with respect to DOD
beneficiaries and issued a letter to manufacturers indicating that
VA's pharmacy vendor would use these prices. DOD officials told us
that they plan to specifically include the FHCC in future manufacturer
pricing arrangements, and in the meantime DOD will evaluate any
objections received from manufacturers.
While workarounds have helped address certain MTF designation-related
issues, another MTF designation-related issue continues to pose
challenges for FHCC operations and health care providers. Navy Bureau
of Medicine and Surgery[Footnote 40] policy regarding the deployment
readiness of Navy and Marine Corps servicemembers requires the
approval of a medical screener assigned to an MTF. The commanding
officer of an MTF assigns specific providers at the facility (medical
officers, physician assistants, nurse practitioners, or Independent
Duty Corpsmen) the responsibility to conduct suitability and medical
assignment screening. For example, for a Navy or Marine Corps
servicemember to be approved for overseas duty, the servicemember must
have a medical, dental, and educational suitability screening, and MTF
medical and dental screeners must sign off on the form stating that
the servicemember is suitable for that assignment. FHCC officials told
us that while the forms are being signed, there is uncertainty as to
whether providers continue to have the authority to sign the forms as
MTF medical screeners because the FHCC is not an MTF, and they have
not seen documentation that confirms whether provider sign-off
authority has changed with the establishment of the FHCC. FHCC
officials said this has created confusion among FHCC providers about
how to interpret DOD policies regarding these documents.
VA and DOD Use Integration Benchmarks to Assess Provision of Care and
Operations at the FHCC, but the Performance Reporting Plan May Not
Yield Transparent, Meaningful, and Accurate Results:
VA and DOD, through FHCC staff, are using the 15 integration
benchmarks set forth in the Executive Agreement (and their
corresponding performance measures) to assess the provision of care
and operations at the FHCC. The plan is to report on these performance
measures using a tool developed by FHCC staff--a scorecard that
generates a monthly summary score. However, the summary score does not
account for data collection variation, FHCC staff have not specified
what target score(s) would indicate successful performance, and the
scorecard initially contained an error, all of which raise concerns
about the FHCC's ability to report transparent, meaningful, and
accurate performance results.
VA and DOD Are Assessing Provision of Care and Operations at the FHCC
through 15 Integration Benchmarks:
The 15 Executive Agreement integration benchmarks, chosen by VA and
DOD, are intended to assess the provision of care and operations at
the FHCC in three main areas of focus: patient and staff satisfaction,
including benchmarks that measure patient and staff feedback; clinical
and administrative functions, such as benchmarks aimed at assessing
patient access to care and clinical productivity; and external
evaluation, including our review among others. The benchmarks vary in
several aspects including whether they were created specifically for
the FHCC or whether they are compared to historical performance before
the facilities were integrated, as well as the frequency of data
collection for each individual benchmark and the specific performance
measures each includes.
The 15 integration benchmarks vary by time frame of establishment.
Most (9) of the 15 integration benchmarks were used by the former
NCVAMC and NHCGL prior to the establishment of the FHCC, while the
remaining benchmarks (6) were established specifically for the FHCC.
(See table 2.) Of the benchmarks that pre-date the establishment of
the FHCC, some have separate measurements for VA and DOD populations,
such as patient satisfaction surveys, as was the case before the FHCC
was established. FHCC officials said they have no short-term plans to
integrate patient satisfaction, because separate measurements allow
them to compare results from before and after the FHCC integration. In
addition, the other benchmarks that pre-date the FHCC integration are
measured for only VA or DOD populations. For example, DOD measures
Navy servicemember medical readiness for duty, which was previously in
place at the former NHCGL to help assess performance of DOD's "mission
critical" operational readiness goals. VA measures health profession
trainee satisfaction, which had been measured at the former NCVAMC and
helps to assess VA's clinical and administrative performance. The 6
remaining benchmarks were created specifically for the FHCC, some of
which were designed to measure aspects of FHCC integrated performance,
such as whether the "information technology solution timeline is met
and has no negative impact on patient safety." Many of these
benchmarks have no historical data to which performance can be
compared.
Table 2: Federal Health Care Center (FHCC) Integration Benchmark
Characteristics by Focus Area and Time Frame of Establishment:
Patient and staff satisfaction:
Integration benchmark: 1. Patient satisfaction measures meet FHCC
targets;
Established before FHCC: Benchmark includes separate VA and DOD
measurement: Patient and staff satisfaction.
Integration benchmark: 2. Staff surveys meet FHCC targets;
Established before FHCC: Benchmark includes separate VA and DOD
measurement: Patient and staff satisfaction.
Integration benchmark: 3. Health profession trainee satisfaction
measures meet FHCC targets;
Established before FHCC: Benchmark is measured for VA only[A].
Clinical and administrative functions:
Integration benchmark: 4. Stakeholders Advisory Council determination
that the FHCC meets both VA and DOD missions[B];
Established before FHCC: Established specifically for FHCC.
Integration benchmark: 5. Clinical and administrative performance
measures meet FHCC targets;
Established before FHCC: Benchmark is measured for VA only.
Integration benchmark: 6. Patient access to care meets FHCC targets;
Established before FHCC: Benchmark includes separate VA and DOD
measurement[C].
Integration benchmark: 7. Evidence-based health care measures meet
FHCC targets;
Established before FHCC: Benchmark includes separate VA and DOD
measurement.
Integration benchmark: 8. Clinical/dental productivity meets FHCC
targets;
Established before FHCC: Established specifically for FHCC.
Integration benchmark: 9. Information technology solution timeline is
met and has no negative impact on patient safety;
Established before FHCC: Established specifically for FHCC.
Integration benchmark: 10. Pre-FHCC academic and clinical research
missions are maintained;
Established before FHCC: Benchmark is measured for VA only.
Integration benchmark: 11. Navy servicemember medical readiness for
duty meets Navy targets;
Established before FHCC: Benchmark is measured for DOD only.
Integration benchmark: 12. Navy advancement/retention meets Navy
targets;
Established before FHCC: Benchmark is measured for DOD only.
External evaluation:
Integration benchmark: 13. Successful annual GAO review;
Established before FHCC: Established specifically for FHCC.
Integration benchmark: 14. Validation of FHCC fiscal reconciliation
model by an annual independent audit;
Established before FHCC: Established specifically for FHCC.
Integration benchmark: 15. Satisfactory facility and clinical
inspection, accreditation, and compliance outcomes from several
external oversight/groups, such as VA and DOD Offices of the Inspector
General and The Joint Commission[D];
Established before FHCC: Established specifically for FHCC[E].
Source: GAO analysis.
[A] The Learners' Perception Survey is a centrally collected VA
trainee satisfaction tool; however, DOD trainees can voluntarily
participate.
[B] The Stakeholders Advisory Council is comprised of members from
various organizations representing FHCC interests, including a local
government representative, as well as officials from TRICARE and
nearby VA medical facilities located in Hines, Illinois, and
Milwaukee, Wisconsin. It provides feedback on how well the FHCC is
meeting customers' needs and whether the FHCC is meeting VA and DOD
missions.
[C] Patient access to care contains three components: VA Primary Care,
DOD Primary Care, and FHCC Specialty Care. FHCC Specialty Care will be
measured using already established VA standards.
[D] The Joint Commission is an independent organization that accredits
and certifies health care organizations and programs in the United
States.
[E] External oversight was previously conducted separately for VA and
DOD facilities. Future inspections, accreditations, and compliance
outcomes will be integrated for the FHCC.
[End of table]
The 15 integration benchmarks are comprised of 38 individual
performance measures. Each of the integration benchmarks has
corresponding performance measures, for a total of 38 individual
performance measures for the 15 benchmarks. For most of the
integration benchmarks, there are at least two individual performance
measures. (See table 3.) FHCC staff have developed a Technical Manual
[Footnote 41] to document their plan for the measurement, data
collection, and reporting of these performance measures.
Table 3: Federal Health Care Center (FHCC) Integration Benchmarks by
Number of Reported Measures:
Integration benchmarks: 1. Patient satisfaction measures meet FHCC
targets;
Number of individual performance measures to be reported: 2.
Integration benchmarks: 2. Staff surveys meet FHCC targets;
Number of individual performance measures to be reported: 2.
Integration benchmarks: 3. Health profession trainee satisfaction
measures meet FHCC targets;
Number of individual performance measures to be reported: 1.
Integration benchmarks: 4. Stakeholders Advisory Council determination
that the FHCC meets both VA and DOD missions[A];
Number of individual performance measures to be reported: 1.
Integration benchmarks: 5. Clinical and administrative performance
measures meet FHCC targets;
Number of individual performance measures to be reported: 4.
Integration benchmarks: 6. Patient access to care meets FHCC targets;
Number of individual performance measures to be reported: 3.
Integration benchmarks: 7. Evidence-based health care measures meet
FHCC targets;
Number of individual performance measures to be reported: 2.
Integration benchmarks: 8. Clinical/dental productivity meets FHCC
targets;
Number of individual performance measures to be reported: 3.
Integration benchmarks: 9. Information technology solution timeline is
met and has no negative impact on patient safety;
Number of individual performance measures to be reported: 1.
Integration benchmarks: 10. Pre-FHCC academic and clinical research
missions are maintained;
Number of individual performance measures to be reported: 2.
Integration benchmarks: 11. Navy servicemember medical readiness for
duty meets Navy targets;
Number of individual performance measures to be reported: 3.
Integration benchmarks: 12. Navy advancement/retention meets Navy
targets;
Number of individual performance measures to be reported: 3.
Integration benchmarks: 13. Successful annual GAO review;
Number of individual performance measures to be reported: 1.
Integration benchmarks: 14. Validation of FHCC fiscal reconciliation
model by an annual independent audit;
Number of individual performance measures to be reported: 1.
Integration benchmarks: 15. Satisfactory facility and clinical
inspection, accreditation, and compliance outcomes from several
external oversight/groups, such as VA and DOD Offices of the Inspector
General and The Joint Commission[B];
Number of individual performance measures to be reported: 9.
Integration benchmarks: Total number of performance measures;
Number of individual performance measures to be reported: 38.
Source: GAO analysis.
[A] The Stakeholders Advisory Council is comprised of members from
various organizations representing FHCC interests, including a local
government representative, as well as officials from TRICARE and
nearby VA medical facilities located in Hines, Illinois, and
Milwaukee, Wisconsin. It provides feedback on how well the FHCC is
meeting customers' needs and whether the FHCC is meeting VA and DOD
missions.
[B] The Joint Commission is an independent organization that accredits
and certifies health care organizations and programs in the United
States.
[End of table]
The 38 performance measures vary by frequency of data collection. FHCC
staff collect data for the performance measures at different time
intervals. (See figure 4.) Depending on the individual measure, data
generally are collected weekly, monthly, quarterly, annually, or every
2 to 3 years. Data for one performance measure is collected both
semiannually and annually, and data may also be collected on a varied
time frame.[Footnote 42]
Figure 4: Variation in Data Collection Frequency for the 38
Performance Measures:
[Refer to PDF for image: pie-chart]
At least monthly[A]: 45%;
Quarterly: 16%;
Varied[C]: 13%;
Annually: 13%;
Every 2 to 3 years[B]: 11%;
Semiannually and annually: 3%.
Source: GAO.
Note: Percentages do not add to 100 due to rounding.
[A] At least monthly includes both weekly and monthly measurements.
[B] Includes measurements collected every 2 years or every 3 years.
[C] Varied measurements include those not on a regular time frame or
unannounced measurements.
[End of figure]
In some cases, data for different performance measures within a single
integration benchmark may be collected at different points in time.
For example, data for the performance measures within the benchmark
"satisfactory facility and clinical inspection, accreditation, and
compliance outcomes from external oversight/groups" vary as to the
times that the respective reviews are conducted; the Joint Commission,
for example, conducts full reviews every 3 years. In addition, data
collection for some measures has not yet begun. For example, the
"validation of FHCC fiscal reconciliation model by annual independent
audit" cannot yet be measured because audits have yet to be performed.
Reporting a Summary Score of Monthly Results May Not Yield
Transparent, Meaningful, and Accurate Performance Information:
FHCC staff have developed a reporting tool in the form of a scorecard
that tracks and summarizes performance data for all 38 performance
measures. The scorecard is designed to calculate scores for each of
the performance measures as well as to generate a summary score every
month. Each of the 38 performance measure scores is determined by
multiplying: (1) a rating based on performance, (2) assigned weights
based on the level of importance, and (3) a fixed multiplier to adjust
the score to a scale of 100. These individual performance measure
scores are then combined into a monthly summary score, also measured
on a scale from 0 to 100. (See figure 5.)
Figure 5: FHCC Performance Scorecard Methodology: Conceptual Model:
[Refer to PDF for image: illustration]
Performance measure #1:
Rating times weight time multiplier equals Performance measure score.
Performance measure #2:
Rating times weight time multiplier equals Performance measure score.
Performance measure #38:
Rating times weight time multiplier equals Performance measure score.
Total of all equals Summary score.
The summary score is determined by summing all 38 performance measure
scores.
Source: GAO.
[End of figure]
Specifically, each performance measure's score is determined by the
following:
1. Each performance measure is rated on a scale from 1 (lowest rating)
to 5 (highest rating) based on how well the measure meets its target
goal, according to definitions set in the FHCC Technical Manual.
2. The Advisory Board weighted each performance measure, assigning the
greatest weight to measures they determined were most critical for
meeting NDAA for Fiscal Year 2010 requirements. Specifically, those
measures concerning DOD's missions of servicemember readiness and VA's
mission of clinical and administrative performance received the
greatest weights. The three weights used, from low to high, are 1
(important), 2 (essential), and 5 (critical).
3. In addition to tracking the trends for each of the performance
measures, the scorecard is designed to calculate a summary score on a
scale of 0 to 100 by adjusting each measure using a fixed
multiplier.[Footnote 43] (See text box below for an example of the
calculation of one performance measure score.)
Sample Performance Measure Score Calculation:
Using the example of the health profession trainee satisfaction
performance measure, a score is determined using the following
information:
1. FHCC staff assigned it a performance rating of 4 – health
professionals are ’somewhat satisfied“ with training.
(This is a baseline rating made before the FHCC was integrated on
October 1, 2010.)
2. The performance measure has a weight of 1 (important).
3. All performance measures are adjusted to the 100 point scale using
a fixed multiplier of 0.2128.
The rating and weight are multiplied together and adjusted to 100 for
a score of 0.8512 (4 x 1 x 0.2128).
FHCC officials told us they designed the scorecard to calculate a user-
friendly, single summary score on a monthly basis and report
performance to the Advisory Board at their regular meetings, which are
typically quarterly.[Footnote 44] However, we identified three areas
of concern with the monthly summary score:
The monthly summary score does not account for varied data collection
time frames. Although the summary score is calculated monthly, data
for all performance measures are not collected on a monthly basis.
Specifically, FHCC staff told us they record no score when no new
monthly data are available for a given performance measure, even when
that measure was not expected to be collected on a monthly basis. In
fact, there may be no single month where complete performance data are
available to be factored into the summary score. For instance, the
health profession trainee satisfaction performance measure, collected
annually, would appear in the scorecard only in the month it was
collected and have no data listed and no rating given for the
remaining 11 months of the year. For more than half the performance
measures, data are collected less frequently than monthly and would be
similarly affected.[Footnote 45] In any given month, fluctuations in
the summary score may be caused by varied data collection, and not
changes in performance, which is not transparent in the scorecard
methodology.
The summary score lacks a set target score(s) to indicate success. The
summary score's ability to provide a meaningful indication of success
is unclear because neither FHCC staff nor the Advisory Board to whom
the scores are reported has established any specific target score(s)
to indicate that the FHCC has achieved success. FHCC officials told us
that the goal of the scorecard is to calculate a summary score for all
38 performance measures on a scale of 0 to 100 to indicate the level
of success of the integration, with a maximum (perfect) score of 100.
While there are specific targets for each of the 38 performance
measures, officials have not determined what score(s) will indicate
overall success of the integration at the end of the 5-year
demonstration. Without establishing a target summary score(s) to
indicate successful FHCC integration, FHCC staff do not have the
ability to gauge progress, thus diminishing the usefulness of
calculating a summary score.
The calculation error raises concerns about accuracy in the scorecard
methodology. Upon review of the FHCC's final version of the scorecard,
we discovered an error in the multiplier used to adjust the scores to
a 100 point scale. With the addition or deletion of performance
measures, the multiplier needs to be recalculated to ensure that the
summary score retains a 100 point scale. We found that when the FHCC
added performance measures, which now total 38, they had not adjusted
the multiplier accordingly. This resulted in a scorecard that
calculated a summary score with a possible total of 119 rather than
100, as the FHCC intended. Although the FHCC has fixed the error and
in March 2011 presented a corrected scorecard to use going forward,
the lack of initial awareness of the error raised concerns about the
accuracy of the results reported using the scorecard.
Conclusions:
The FHCC is a 5-year demonstration project that has the potential to
be a model for future VA and DOD integration efforts. However, IT
implementation delays, the lack of MTF designation, and concerns about
the use of a summary score to report on FHCC performance may impact
FHCC officials' ability to provide the information necessary for
Congress to determine whether to continue the FHCC beyond the 5-year
demonstration and whether the model should be replicated elsewhere.
While the delays implementing the IT integration area of the Executive
Agreement have been largely outside the control of FHCC officials,
they may impact FHCC officials' ability to operate the FHCC as a fully
integrated facility. As we recommended in our February 2011 report, we
continue to believe that the Secretaries of VA and DOD should
strengthen their ongoing efforts to establish the joint IT system
capabilities for the FHCC by developing plans that include scope
definition, cost and schedule estimation, and project plan
documentation and approval.[Footnote 46]
The lack of an MTF designation and its related challenges may affect
further progress in implementing the FHCC demonstration. The
administrative burden and uncertainty resulting from the lack of MTF
status may hinder FHCC officials' ability to efficiently operate the
FHCC until DOD clarifies the facility's status relative to the rest of
DOD's health care system or obtains a legislative change to designate
the FHCC as an MTF.
As a reporting tool, the FHCC scorecard has the potential to be useful
in tracking performance results over time. However, calculating a
monthly summary score for the FHCC scorecard raises concerns about
FHCC officials' ability to convey transparent, meaningful, and
accurate performance information to VA and DOD officials and other
stakeholders. If the monthly summary score calculations do not account
for data collection variation, do not specify a target score(s) that
would indicate successful performance, or continue to have errors,
then the scorecard's ability to gauge FHCC performance results is
unclear. Until these concerns are addressed, the Secretaries of VA and
DOD and Congress will be unable to make fully informed decisions as to
whether the FHCC model should continue and whether it should be
replicated in other locations.
Recommendations for Executive Action:
To ensure that FHCC officials are able to efficiently operate the FHCC
and uncertainty regarding the lack of MTF status is resolved, we
recommend that the Secretary of Defense seek a legislative change to
designate the FHCC as an MTF.
To ensure that the plan to report on FHCC performance results is
transparent and provides meaningful information that can assist VA and
DOD leadership and Congress in decision making with regard to the
future of the FHCC or other VA/DOD integration efforts, we recommend
that the Secretaries of Veterans Affairs and Defense direct FHCC
leadership to conduct further evaluation of the scorecard reporting
tool and its methodology and make revisions that will better ensure
the transparency and accuracy of the information reported.
Agency Comments and Our Evaluation:
DOD and VA each provided comments on a draft of this report. In its
comments, DOD concurred with one of our two recommendations to the
Secretary of Defense. (DOD's comments are reprinted in appendix I.)
VA, in its comments, generally agreed with our conclusions and
concurred with our recommendation to the Secretary of VA. (VA's
comments are reprinted in appendix II.) In addition, both VA and DOD
provided technical comments which we have incorporated as appropriate.
DOD agreed with our finding that the lack of an MTF designation for
the FHCC has posed some challenges and confusion; however, the
department did not concur with our recommendation to the Secretary of
Defense to seek a legislative change to designate the FHCC as an MTF.
Rather than seek a legislative change as we recommended, DOD stated
that it will consider seeking legislative authorization for the use of
personal services contracts at the FHCC--one of the challenges we
discuss in this report. In its response, DOD stated that it
anticipates that as the FHCC stabilizes and matures, the confusion
among employees and providers at the FHCC due to the lack of an MTF
designation will dissipate and that each of the challenges described
in the draft report has been addressed through workarounds. We
disagree with DOD's reasoning and maintain that our recommendation
should be implemented in order to eliminate the need for the current
workarounds and to address any future problems arising from the lack
of an MTF designation for the FHCC. Since the FHCC is now providing
the services that the NHCGL once did, it should have the same MTF
designation the NHCGL had in order to carry out its work as
efficiently as possible. Eliminating the need for workarounds could
free staff time and contribute to increased efficiency of patient care
and operations at the FHCC. In addition, if the FHCC model of
collaboration between VA and DOD is replicated elsewhere, the same
workarounds will have to be implemented in order to overcome the lack
of an MTF designation. If our recommendation were implemented, it
would set a precedent for future VA and DOD integrations and help make
the integration process smoother.
VA and DOD concurred with our recommendation to the Secretaries of
Veterans Affairs and Defense to direct FHCC leadership to conduct
further evaluation of the scorecard reporting tool and its
methodology, and make revisions that will better ensure the
transparency and accuracy of the information reported. In its
comments, VA describes the department's recent actions to implement
this recommendation. VA acknowledged that the varying reporting
timelines for performance measures resulted in an artificially low
monthly summary score in some months when using the original
methodology. VA stated, in its comments, that it has changed the
calculation process for the scorecard's monthly score to address this
issue. Specifically, FHCC staff will populate the scorecard with a
score for each measure every month using either data acquired that
month, or the most recent available data for those measures. VA states
that this will allow for a more accurate comparison of performance
from month to month.
We are sending copies of this report to the Secretary of Defense,
Secretary of Veterans Affairs, and appropriate congressional
committees. In addition, the report will be available at no charge on
the GAO Web site at [hyperlink, http://www.gao.gov].
If you or your staffs have any questions about this report, please
contact Debra A. Draper at (202) 512-7114 or draperd@gao.gov. Contact
points for our Offices of Congressional Relations and Public Affairs
may be found on the last page of this report. GAO staff who made major
contributions to this report are listed in appendix III.
Signed by:
Debra A. Draper:
Director, Health Care:
List of Committees:
The Honorable Carl Levin:
Chairman:
The Honorable John McCain:
Ranking Member:
Committee on Armed Services:
United States Senate:
The Honorable Patty Murray:
Chairman:
The Honorable Richard Burr:
Ranking Member:
Committee on Veterans' Affairs:
United States Senate:
The Honorable Howard P. "Buck" McKeon:
Chairman:
The Honorable Adam Smith:
Ranking Member:
Committee on Armed Services:
House of Representatives:
The Honorable Jeff Miller:
Chairman:
The Honorable Bob Filner:
Ranking Member:
Committee on Veterans' Affairs:
House of Representatives:
[End of section]
Appendix I: Comments from the Department of Defense:
Note: Page numbers in the draft may differ from those in this report.
The Assistant Secretary Od Defense:
Health Affairs:
1200 Defense Pentagon:
Washington, DC 20301-1200:
June 17, 2011:
Ms. Debra Draper:
Director, Health Care:
U.S. Government Accountability Office:
441 G. Street, N.W.
Washington, DC 20548:
Dear Ms. Draper:
This is the Department of Defense (DoD) response to the Government
Accountability Office (GAO) Draft Report GA0-11-570, "VA and DOD
Health Care: First Federal Health Care Center Established, but
Implementation Concerns Need to be Addressed," dated May 18, 2011 (GAO
Code - 290866).
The Department appreciates the opportunity to comment on the draft
report. The Department non-concurs with the first recommendation, as
written, for the reasons provided in the enclosure and concurs with
the second recommendation. Also enclosed are specific, technical
comments regarding details contained in the body of the report that
the Department believes will add clarity and some instances of
improved accuracy.
Please direct any questions to the points of contact on this matter,
Mr. Kenneth E. Cox (Functional) and Mr. Gunther J. Zimmerman (Audit
Liaison). Mr. Cox may be reached at (703) 681-4258, or
Kenneth.Cox@tma.osd.mil. Mr. Zimmerman may be reached at (703) 681-
3492, ext. 4065, or Gunther.Zimmerman@tma.osd.mil.
Sincerely,
Signed by:
Jonathan Woodson, M.D.
Enclosures:
1. Overall Comments.
2. Technical Comments.
3. Department of the Navy Comments.
[End of letter]
Government Accountability Office Draft Report ” Dated May 18, 2011
(GAO Code - 290866):
"VA and DOD Health Care: First Federal Health Care Center Established,
but Implementation Concerns Need to be Addressed"
Department Of Defense Comments:
Recommendation 1: The Government Accountability Office (GAO)
recommends the Secretary of Defense (SecDef) seek legislative change
to designate the First Federal Health Care Center (FHCC) as a Military
Treatment Facility (MTF).
DoD Response: The Department of Defense (DoD) agrees with the finding
that the issue of MTF designation has posed some challenges and
confusion. It is anticipated that as the operation stabilizes and
matures, the confusion among employees and providers at FHCC cited in
the report will dissipate. Each of the challenges described in the
report has been addressed through what the draft report refers to as
"workarounds." However, Navy Medicine has suggested consideration of
legislative language that would specifically authorize the use of
personal services contracts at FHCC. At this point in the operation of
the FHCC, the Department non-concurs with the GAO draft recommendation
to seek MTF status for FHCC, as written, but will consider in the
legislative proposal development process Navy Medicine's suggestion
regarding personal services contracting authority.
Recommendation 2: GAO recommends that the Secretaries of Veterans
Affairs and DoD direct FHCC leadership to conduct further evaluation
of the scorecard reporting tool and its methodology, and make
revisions that will better ensure the transparency and accuracy of the
information reported.
DoD Response: DoD concurs with the recommendation to further evaluate
and make revisions to improve the transparency and accuracy of the
information being monitored and reported.
[End of section]
Appendix II: Comments from the Department of Veterans Affairs:
Note: Page numbers in the draft may differ from those in this report.
Department Of Veterans Affairs:
Washington DC 20420:
June 17, 2011:
Ms. Debra A. Draper:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Draper:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, "VA And DOD Health Care:
First Federal Health Care Center Established, but Implementation
Concerns Need to be Addressed," (GA0-11-570) and generally agrees with
GAO's conclusions and concurs with GAO's recommendation to the
Department.
The enclosure specifically addresses GAO's recommendation and provides
comments to the report. VA appreciates the opportunity to comment on
your draft report.
Sincerely,
Signed by:
John R. Gingrich:
Chief of Staff:
Enclosure:
[End of letter]
Enclosure:
Department of Veterans Affairs (VA) Comments to Government
Accountability Office (GAO) Draft Report:
VA And DOD Health Care: First Federal Health Care Center Established,
but Implementation Concerns Need to be Addressed (GA0-11-570):
GAO Recommendation: To ensure that the plan to report on FHCC
performance results is transparent and provides meaningful information
that can assist VA and DOD leadership and Congress in decision-making
with regard to the future of the FHCC or other VA/DOD integration
efforts, we recommend that the Secretaries of Veterans Affairs and
Defense direct FHCC leadership to conduct further evaluation of the
scorecard reporting tool and its methodology and make revisions that
will better ensure the transparency and accuracy of the information
reported.
VA response: Concur. The Veterans Health Administration (VHA) has
taken action to address these issues. As GAO notes, each performance
measure has an appropriate reporting timeframe that is relevant to the
specific measure. Some, such as outpatient clinical performance data,
are available as often as monthly (but not weekly, as suggested on
pages 25 and 26). Others may take longer, for example, The Joint
Commission evaluations may take three years to occur. These intrinsic
differences caused blanks in early versions of the Scorecard, and the
blanks caused artificially low monthly total scores.
In March 2011, VHA recognized this problem and changed the calculation
process for the Scorecard "monthly score." Now, a score for all
possible measures is calculated each month using either data acquired
that month, or the most current available data for those cells that do
not have a monthly update. This produces a tentative monthly score
that can be used to compare to prior monthly performances.
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Debra A. Draper, (202) 512-7114 or draperd@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Marcia A. Mann, Assistant
Director; Jill K. Center; Kaycee M. Glavich; E. Jane Whipple; and
Malissa G. Winograd made key contributions to this report. Lisa A.
Motley provided legal support and Jennie F. Apter assisted in the
message and report development.
[End of section]
Footnotes:
[1] 38 U.S.C. § 8111. The Department of Veterans Affairs was
previously known as the Veterans Administration.
[2] VA beneficiaries include veterans of military service and certain
dependents and survivors; DOD beneficiaries include active duty
servicemembers and their dependents, medically eligible National Guard
and Reserve servicemembers and their dependents, and military retirees
and their dependents and survivors. Active duty personnel include
Reserve component members on active duty for at least 30 days.
[3] The other eight joint venture locations are: Anchorage, Alaska;
Fairfield, California; Key West, Florida; Honolulu, Hawaii; Las Vegas,
Nevada; Albuquerque, New Mexico; Biloxi, Mississippi; and El Paso,
Texas.
[4] The NDAA for Fiscal Year 2010 authorized the Secretaries of DOD
and VA to enter into an agreement to establish a joint medical
facility consisting of a new Navy ambulatory care center, parking
structure, and supporting structures and facilities, as well as
related medical personal property and equipment. Pub. L. No. 111-84,
tit. XVII, 123 Stat. 2190, 2567-74 (2009). The FHCC was formally
established as the Captain James A. Lovell Federal Health Care Center
for which VA and DOD integrated the NCVAMC and its community based
outpatient clinics, the new ambulatory care center, and the Navy Fleet
Medicine clinics associated with Naval Station Great Lakes into a
single organizational structure.
[5] This Commission was established by Congress to provide an
independent review and analysis of DOD's recommendations for
realigning or closing military installations. Defense Base Closure and
Realignment Act of 1990, Pub. L. No. 101-510, div. B, tit. XXIX, pt.
A, § 2902, 104 Stat. 1485, 1808-10.
[6] The VA established the Capital Asset Realignment for Enhanced
Services in October 2000 as an ongoing process through which VA
systematically studies the health care needs of veterans.
[7] The NHCGL included a main clinic and three branch clinics that
provided health care services to Navy recruits as well as active duty
personnel and their families.
[8] Pub. L. No. 111-84, § 1702, 123 Stat. 2190, 2568-70 (2009).
[9] Pub. L. No. 111-84, § 1701(e), 123 Stat. 2190, 2568 (2009).
[10] In the area of financial systems, we did not perform a financial
audit of the FHCC, but rather assessed its progress in establishing a
model for joint funding.
[11] GAO, Electronic Health Records: DOD and VA Should Remove Barriers
and Improve Efforts to Meet Their Common System Needs, [hyperlink,
http://www.gao.gov/products/GAO-11-265] (Washington, D.C.: Feb. 2,
2011).
[12] Through the remainder of this report, we refer to the Naval
Hospital Great Lakes by its subsequent name, the NHCGL.
[13] According to DOD the transfer of inpatient services and the
redesignation of the naval hospital to a naval health clinic
implemented a 2005 Base Realignment and Closure recommendation.
[14] As of April 2011 the information technology components that
support these ancillary services were not fully operational, although
FHCC officials told us the services themselves were available to
patients.
[15] This figure is an FHCC estimate including VA civilians and
contractors, prior Navy civilians converted to VA civilians, active
duty servicemembers, and Navy contractors.
[16] The Joint Executive Council is made up of officials from VA and
DOD and provides senior leadership for collaboration and resource
sharing and oversees the Health Executive Council which oversees the
cooperative efforts of each department's health care organizations.
[17] In April 2011, the Department of Defense and Full-Year Continuing
Appropriations Act, 2011 provided funds for VA and DOD to transfer to
the Joint Fund. Prior to this point, the FHCC received funding from VA
and DOD through an alternative funding mechanism outlined in the
Executive Agreement.
[18] The Stakeholders Advisory Council membership includes
representation from local government, TRICARE, and nearby VA medical
facilities located in Hines, Illinois, and Milwaukee, Wisconsin.
[19] There are six clinical and administrative divisions at the FHCC:
Patient Services, which includes laboratory and radiology services as
well as staff training and education; Dental Services, including oral
surgery and general dentistry; Patient Care, which includes the
Departments of Surgery, Ambulatory Care, and other health care
provided at the facility; Fleet Medicine, which oversees the clinics
providing services to Navy servicemembers; Facility Support, which
includes security and facility management; and Resources, which
oversees financial management and human resources among other
functions.
[20] TRICARE offers three basic options for its beneficiaries: (1) a
managed care option called TRICARE Prime, (2) a preferred-provider
option called TRICARE Extra, and (3) a fee-for-service option called
TRICARE Standard. An additional option, TRICARE for Life, supplements
Medicare coverage for beneficiaries enrolled in Medicare Part B.
Beneficiaries using TRICARE Extra are considered to be TRICARE
Standard participants and are included as such in the priority list.
[21] The Civilian Health and Medical Program of the Department of
Veterans Affairs provides health care coverage for spouses, widows,
and children of veterans who are permanently and totally disabled from
a service-connected disability, or who died from a service-connected
disability or in the line of duty. See 38 U.S.C. § 1781.
[22] An Institutional Review Board is an entity formally designated to
review and monitor biomedical and behavioral research in clinical
trials involving human subjects, with the intended purpose of
protecting the rights and welfare of the research subjects.
[23] On April 15, 2011, the Department of Defense and Full-Year
Continuing Appropriations Act, 2011, which appropriates funding for VA
and DOD to transfer to the Joint Fund, became law. The act provides
that VA may transfer to the Joint Fund up to $235,360,000, plus
reimbursements and collections, and that DOD may transfer up to
$132,200,000. VA and DOD may transfer additional funds upon written
notification to the appropriations committees. See Pub. L. No. 112-10,
div. A, § 8107, div. B, §§ 2017, 2018, 125 Stat. 38 (2011).
[24] Pub. L. No. 111-84, § 1704(d), 123 Stat. 2190, 2573 (2009).
[25] Pub. L. No. 111-84, § 1703(a), 123 Stat. 2190, 2570 (2009).
[26] Independent duty corpsmen are enlisted personnel who receive
advanced training to provide treatment and administer medications. At
the FHCC, independent duty corpsmen are allowed to practice where an
active duty credentialed and privileged provider practices.
[27] See for example, VA Office of the Inspector General, Healthcare
Inspection: Alleged Quality of Care Issues Captain James A. Lovell
Federal Health Care Center, North Chicago, Illinois, Report No. 11-
00163-109 (Washington, D.C., VA Office of the Inspector General, Mar.
2, 2011); and Mathematica Policy Research, North Chicago, IL Mental
Health Residential Rehabilitation Treatment Programs: VISN 12, Station
Code 556 Follow-Up Quality Review Report (Princeton, N.J., Mathematica
Policy Research, Dec. 21, 2010).
[28] The Joint Commission is an independent organization that
accredits and certifies health care organizations and programs in the
United States.
[29] See Pub. L. No. 111-84, § 1701(d), 123 Stat. 2190, 2568 (2009).
[30] VA's electronic health record system is called the Veterans
Health Information Systems and Technology Architecture (VistA) and
DOD's electronic health record system is called the Armed Forces
Health Longitudinal Technology Application (AHLTA).
[31] The Facilities Operational Infrastructure Strategic Working Group
is made up of headquarters-level VA and DOD representatives including
enterprise infrastructure specialists who can address systems
engineering issues and representatives of the departments' network
security groups.
[32] See Institute of Electrical and Electronics Engineers (IEEE),
IEEE/EIA Guide for Information Technology, IEEE/EIA 12207.1-1997
(April 1998) and Carnegie Mellon Software Engineering Institute,
Capability Maturity Model Integration for Acquisition, Version 1.2
(November 2007).
[33] See [hyperlink, http://www.gao.gov/products/GAO-11-265].
[34] While VA and DOD officials confirmed that the initial
capabilities (single sign-on, single patient registration, and orders
portability) will be capable of being exported, the officials also
said that customization will be needed at each new site.
[35] The Navy Fleet Medicine clinics at the FHCC continue to have an
MTF designation, and serve military personnel.
[36] The NDAA for Fiscal Year 2010 provided that the facility, defined
for purposes of the statute as the new Navy ambulatory care center,
parking structure, and supporting structures and facilities, as well
as related medical personal property and equipment, "may be treated as
a facility of the uniformed services" for purposes of eligibility for
DOD health care. See Pub. L. No. 111-84, § 1705(a), 123 Stat. 2190,
2573 (2009). Neither "facility of the uniformed services" nor MTF is
defined in statute or regulation, but the two are generally used
interchangeably.
[37] Active duty servicemembers and their dependents enrolled in
TRICARE Prime pay no co-payments for inpatient or outpatient health
care services for care received from their primary care manager or
with a referral. See 32 C.F.R. §§ 199.17(m), 199.18(d)(1), (e)(1)
(2010).
[38] "TRICARE Co-Pay Waiver at Captain James A. Lovell Federal Health
Care Center Demonstration Project," 75 Fed. Reg. 59,237 (Sept. 27,
2010).
[39] Personal service contracts are a type of contract used within DOD
to acquire (1) direct health care services provided in MTFs; (2)
health care services at locations outside of MTFs (such as military
entrance processing stations); and (3) services of clinical
counselors, family advocacy program staff, and victims' services
representatives, provided to eligible beneficiaries in MTFs or
elsewhere. See 10 U.S.C. § 1091; 48 C.F.R. § 237.104(b)(2)(A) (2010).
[40] The Navy Bureau of Medicine and Surgery is the headquarters
command for Navy Medicine and is the site where the policies and
direction for Navy medicine are developed.
[41] The FHCC's Technical Manual follows the structure of the
Technical Manual developed by the Veterans Health Administration's
Office of Quality and Performance, which focuses on medical research,
clinical information, and patient outcomes.
[42] A varied time frame could be due to data collection that is not
on a regular time frame or is unannounced.
[43] The multiplier was determined by multiplying each performance
measure's assigned weight with a perfect rating of 5 to determine the
total maximum summary score; 100 is then divided by the total maximum
summary score, resulting in the fixed multiplier of .2182 used to
adjust the score for each performance measure to a scale of 0 to 100.
[44] As of April 2011, FHCC officials have reported to the Advisory
Board once in March 2011.
[45] As of March 2011, there has not been a single month since the
FHCC was established when the scorecard included complete data for all
38 performance measures. The month with the most data included in the
scorecard was October 2010, for which FHCC staff collected complete
data for 18 of the 38 performance measures.
[46] See [hyperlink, http://www.gao.gov/products/GAO-11-265].
[End of section]
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