Tuesday, July 27, 2010

VA' Directive 2010-004, Authority to Settle Tort Claims

Department of Veterans Affairs
VHA DIRECTIVE 2010-004
Veterans Health Administration
Washington, DC 20420
January 14, 2010
DELEGATION OF AUTHORITY TO SETTLE TORT CLAIMS
1. PURPOSE: This Veterans Health Administration (VHA) Directive establishes nationwide policy permitting Veterans Integrated Service Network (VISN) Directors and Department of Veterans Affairs (VA) medical facility Directors to consider, ascertain, adjust, determine, compromise, and settle any claim for $2,500 or less that arises out of VHA operations and is asserted under the Federal Tort Claims Act.
2. POLICY: It is VHA policy to implement the revised Title 38 Code of Federal Regulations (CFR) 14.600 that was published in the Federal Register on August 30, 1999, effective from the same date.
3. ACTION
a. Settlement authority for Federal Tort Claims for $2,500 or less and arising out of VHA operations for money claims filed under the Federal Tort Claims Act is extended to Network Directors and facility Directors. This delegation is enumerated under 38 CFR 14.600. It covers damage or loss of property or personal injury or death, caused by the negligent or wrongful act or omission of a Government employee while acting within the scope of the employee’s office or employment.
b. Settlement authority for Federal Tort Claims for $2,500 or less and arising out of VHA operations to reconsider final denial of a claim by a Network Director or facility Director is resident with the Regional Counsel with jurisdiction over the geographic area where the occurrence complained of arose. The denial letter needs to advise the claimant(s) of the right to request reconsideration by the Regional Counsel; it should also include the following language: “In the alternative, if you are dissatisfied with the action taken on your claim, you may file suit in accordance with the Federal Tort Claims Act, Title 28, United States Code, Section 1346(b) and 2671-2680, which provides that a tort claim that is administratively denied may be presented to a Federal district court for judicial consideration. Such a suit must be initiated within 6 months after the date of the mailing of this notice of final denial as shown by the date of this letter (Title 28, United States Code, Section 2401(b)). If you do initiate such a suit, you are further advised that the proper party defendant is the United States, not VA.” A copy of the denial letter, and a copy of the claim, should be provided to the Regional Counsel.
c. Regardless of the amount, information on medical malpractice settlements must continue to be reported to the Office of Medical-Legal Affairs (11ML) which is co-located at the VA Medical Center Buffalo, NY. Upon receipt of settlement notice, that office undertakes any necessary collection of additional evidence to support peer review and consideration of reporting to the National Practitioners Data Bank. A copy of a settled tort claim needs to be furnished to Regional Counsel and the Office of Medical-Legal Affairs (11ML).
THIS VHA DIRECTIVE EXPIRES JANUARY 31, 2015
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4. REFERENCE: None.
5. FOLLOW-UP RESPONSIBILITY: The Office of Patient Care Services, (11) is responsible for the contents of this Directive. Questions need to be addressed to 202-461-7590.
6. RESCISSION: VHA Directive 99-066 is rescinded. This VHA Directive expires
January 31, 2015.
JGerald M. Cross, MD, FAAFP
Acting Under Secretary for Health
DISTRIBUTION:
E-mailed to the VHA Publications Distribution List 1/22/2010

VA's Adverse Event Disclosure, Directive 2008-002

Department of Veterans Affairs
VHA DIRECTIVE 2008-002
Veterans Health Administration
Washington, DC 20420
January 18, 2008
DISCLOSURE OF ADVERSE EVENTS TO PATIENTS
1. PURPOSE: This Veterans Health Administration (VHA) Directive provides policy pertaining exclusively to the disclosure of adverse events, related to clinical care, to patients or their personal representatives. NOTE: Information pertaining to adverse events in research can be found in VHA Handbook 1200.5 and VHA Handbook 1058.01.
2. BACKGROUND
a. VHA facilities and individual VHA providers have an ethical and legal obligation to disclose to patients adverse events that have been sustained in the course of their care, including cases where the adverse event may not be obvious or severe, or where the harm may only be evident in the future.
(1) The patient is free to involve family members in the disclosure process.
(2) If the patient is deceased, incapacitated, or otherwise unable to take part in a process of adverse event disclosure, the process needs to involve the patient’s personal representative and anyone who is designated by the personal representative.
b. Disclosure of adverse events to patients or their personal representatives is consistent with VHA core values of trust, respect, excellence, commitment, and compassion. Providers have an ethical obligation to be honest with their patients. Honestly discussing the difficult truth that an adverse event has occurred demonstrates respect for the patient, professionalism, and a commitment to improving care.
c. Clinicians and organizational leaders are to work together to ensure that appropriate disclosure to patients or their personal representatives is a routine part of the response to a harmful or potentially harmful adverse event. Telling patients or their personal representatives about adverse events, or potentially harmful adverse events, is never easy, however, it needs to be done and with skill and tact.
d. Disclosure of adverse events and the reporting of adverse events to regulatory agencies are separate requirements. Actions taken to disclose adverse events to patients according to this Directive in no way obviate the need to report adverse events (and close calls) as required under VHA Handbook 1050.01. Internal reporting through the adverse event and close call reports are protected from disclosure under Title 38 United States Code (U.S.C.) Section 5705. Records protected under 38 U.S.C. Section 5705, that is, quality management and safety activities records, may not be subsequently used as the source of information communicated in the disclosure of an adverse event.
THIS VHA DIRECTIVE EXPIRES JANUARY 31, 2013
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NOTE: This Directive is consistent with The Joint Commission requirement that patients and, when appropriate, their families be told of "unanticipated outcomes" of care (Standard - Ethics, Rights, and Responsibilities (RI) 2.90, 2006).
e. Despite the general obligation to disclose adverse events to patients, there are legal restrictions on the information that can be shared. The information communicated to the patient comes from those involved in the adverse event and from factual information in the patient’s medical record.
(1) Confidentiality statutes and regulations, such as the Privacy Act and the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, limit disclosure of any record containing a patient’s personal information to others without the patient’s authorization or other legal authority. NOTE: The patient’s personal representative is authorized to have access to the patient’s protected health information except as noted in this subparagraph and subparagraph 2e(2) (see VHA Handbook 1605.1).
(2) Under 38 U.S.C. Section 7332, VHA may not disclose information related to the patient’s treatment for substance abuse (including alcohol), sickle cell anemia disease, or infection with the Human Immunodeficiency Virus (HIV) to others, even after a patient’s death without a “special authorization” or other exception. Questions about release of such information in the case of an adverse event are to be referred to the facility’s Privacy Officer. NOTE: Consultation with VHA’s Privacy Officer may also be necessary.
(3) Under 38 U.S.C. Section 5705, VHA may not communicate to patients, or their personal representatives, information that is obtained from documentation of certain quality management activities, such as root cause analyses or patient safety registry records. Rather, the information communicated must come from those involved in the adverse event and from factual information in the patient’s medical record. NOTE: Specific questions regarding sources of information that may not be disclosed or released to the patient or representative may be found in VHA Handbook 1605.1. Other guidance is available from VHA’s Privacy Officer.
f. Definitions
(1) Adverse Event. Adverse events are untoward incidents, therapeutic misadventures, iatrogenic injuries, or other adverse occurrences directly associated with care or services provided within the jurisdiction of a medical center, outpatient clinic, or other VHA facility. NOTE: To determine which incidents need to be considered for Root Cause Analysis, the definition of adverse event in the VHA Handbook 1050.01 is be used.
(2) Disclosure of Adverse Events. For the purpose of this Directive, the phrase “disclosure of adverse events” refers to the forthright and empathetic discussion of clinically significant facts between providers or other VHA personnel and patients or their personal representatives about the occurrence of a harmful adverse event, or an adverse event that could result in harm in the foreseeable future. VA recognizes three types of disclosure of adverse events:
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(a) Clinical Disclosure of Adverse Events. Clinical Disclosure of Adverse Events is an informal process for informing patients or their personal representatives of harmful adverse events related to the patient’s care. In a clinical disclosure, one or more members of the clinical team provides factual information to the extent it is known, expresses concern for the patient’s welfare, and reassures the patient or personal representative that steps are being taken to investigate the situation, remedy any injury, and prevent further harm. The clinical disclosure of adverse events is considered a routine part of clinical care, and needs to be made by the attending or senior practitioner, or designee. Additional guidance on what must be disclosed, when, and how is provided in Attachment A.
(b) Institutional Disclosure of Adverse Events. In cases resulting in serious injury or death, or those involving reasonably expected serious injury, or potential legal liability, a formal process is needed; this process is called institutional disclosure of adverse events. Institutional disclosure of adverse events should not take place until organizational leaders, including, as appropriate, the facility Director, Chief of Staff, Nurse Executive, and members of the treatment team, have conferred with Regional Counsel and addressed what is to be communicated, by whom and how. In an institutional disclosure the patient(s) or personal representative(s) and any family member(s) designated by the patient or personal representative are invited to meet with institutional leaders and others, as appropriate. An apology is made, and information about compensation and procedures available to request compensation is provided, when appropriate. Additional guidance on what must be disclosed, when, and how is provided in Attachment A. Documentation of institutional disclosure using the Computerized Patient Record System (CPRS) template is mandatory (see Att. B).
(c) Large Scale Disclosure of Adverse Events. “Large scale” is defined as involving a large number of patients, even if at a single facility. For large scale disclosures of adverse events, collaboration with Department of Veterans Affairs (VA) Central Office is required for evaluation and planning. Decisions regarding large scale disclosure of adverse events will be made by the Principal Deputy Under Secretary for Health and may include consultation with the Clinical Risk Assessment Advisory Board (CRAAB). NOTE: Additional guidance on large scale disclosure is provided in Attachment C.
(3) Patient’s Personal Representative. A personal representative of the individual is any person(s) who, under applicable law, has the authority to act on behalf of the individual when making decisions related to health care or to act on behalf of a deceased individual. The personal representative of an individual has the ability to exercise the individual’s rights. A personal representative for the purposes of this Handbook does not necessarily equate to a surrogate for the informed consent process (see Title 38 Code of Federal Regulations (CFR) §17.32(e) for authorized surrogates for informed consent; see VHA Handbook 1605.1 for details on personal representatives).
(4) The Clinical Risk Assessment Advisory Board (CRAAB). The CRAAB is a VA Central Office board which will be convened at the request of the Deputy Under Secretary for Health for Operations and Management (10N) in response to actual or potential adverse events which may not be limited to a small number of patients, especially “large-scale” disclosures as defined in subparagraph 2f(2)(c). Notification of VA regarding the potential need for large scale
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disclosure does not eliminate the requirement for adverse event reporting and follow-up as described in VHA Handbook 1050.01.
3. POLICY: It is VHA Policy that disclosure of adverse events that cause harm to patients to be routine practice.
4. ACTION
a. Facility Director. The facility Director is responsible for:
(1) Ensuring that VHA health care providers communicate, as appropriate, harmful adverse events openly and promptly with patients and/or patients’ personal representatives and that, when necessary, the process for large scale adverse event disclosure is appropriately initiated.
(2) Ensuring the facility policy on disclosure of adverse events to patients is in alignment with this Directive by September 30, 2008.
(3) Promoting a ethical health care environment in which appropriate disclosure of adverse events becomes routine practice.
(4) Ensuring that clinical staff are aware of this Directive and the local facility policy, and implementing them. NOTE: Practitioners are encouraged to confer with the local ethics consultation service, their Service Chief, Chief of Staff, Nurse Executive, Regional Counsel, Risk Manager, or Patient Safety Manager to clarify any concerns about how best to communicate this information and what adverse events are applicable to the disclosure of adverse event process.
(5) Ensuring that staff members involved in adverse events and subsequent disclosure processes are provided with adequate support systems and ensuring that staff members are aware of them.
(6) Ensuring that adverse events are appropriately disclosed in collaboration with the Chief of Staff, Risk Manager, Nurse Executive and the treatment team. Appropriate disclosure includes the following:
(a) Ensuring that as part of the disclosure process, patients or their personal representatives are offered appropriate options, such as arrangements for a second opinion, additional monitoring, expediting clinical consultations, bereavement support, or whatever might be appropriate depending on the adverse event.
(b) Ensuring that veteran patients or their personal representatives are made aware of their rights under 38 U.S.C. Section 1151, made aware of the Tort Claim process, and provided information concerning the necessary forms.
(c) Ensuring that adverse events that may require large scale patient disclosures are thoroughly documented and communicated to the VISN Director.
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(7) Ensuring that adverse events are documented in CPRS.
(a) Institutional disclosures must utilize the “Disclosure of Adverse Event Note” template (see Att. B). Specific documentation in CPRS is not required for all clinical disclosures, as some clinical disclosures may be considered a part of routine care; however, for significant adverse events, it is appropriate to document the clinical disclosure of an adverse event, in a progress note or using the “Disclosure of Adverse Event Note” template.
(8) Ensuring the VISN Director and the Deputy Under Secretary for Health for Operations and Management are informed of any significant, critical, urgent adverse events.
b. Risk Manager or Patient Safety Manager. The Risk Manager or Patient Safety Manager is responsible for:
(1) Immediately notifying the Nurse Executive, Chief of Staff, or Facility Director about the discovery of a significant adverse event that is brought to their attention, especially those that may require institutional disclosure or a decision regarding a large scale disclosure of adverse events.
(2) Establishing a regular dialogue with Regional Counsel and requesting that Regional Counsel educate providers as needed about the legal dimensions of institutional disclosure of adverse events, its documentation, and its relationship to the Federal Tort Claims Act.
c. Chief of Staff and Nurse Executive. The Chief of Staff and Nurse Executive are responsible for:
(1) Immediately notifying the Facility Director about the discovery of a significant adverse event that is brought to their attention.
(2) Participating in discussions with others, e.g., clinicians, facility top management team, Regional Counsel, VISN staff, patients, or personal representatives, as appropriate, concerning the adverse event.
d. The Veterans Integrated Service Network (VISN) Director. The VISN Director, or designee, is responsible for:
(1) Promoting an ethical health care environment in which appropriate disclosure of adverse events becomes routine practice.
(2) Ensuring that a collaborative relationship between Regional Counsel and VA medical center staff is established to ensure appropriate and timely disclosure of adverse events to patients.
(3) Ensuring that adverse events that may require large scale patient disclosures are thoroughly documented and communicated to the Office of the Deputy Under Secretary for Health for Operations and Management.
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e. Deputy Under Secretary for Health for Operations and Management (10N). The Deputy Under Secretary for Health for Operations and Management is responsible for reviewing those adverse events that may require large scale adverse event disclosures to determine if the adverse event needs to be sent to the CRAAB for its review and recommendations. If there are clinical issues, consultation with the Chief Consultant, Medical-Surgical Service of Patient Care Services and other senior officials may be necessary to assist in the decision making process.
f. The Clinical Risk Assessment Advisory Board (CRAAB)
(1) The CRAAB is made up of appropriate representatives from the Office of the Deputy Under Secretary for Health for Operations and Management, National Center for Ethics in Health Care, Office of Nursing Services, Office of Quality and Performance, National Center for Patient Safety, Office of Patient Care Services, and Office of Public Health and Environmental Hazards, as well as subject matter experts from VHA or non-VA experts as needed.
(a) The CRAAB is chaired by the Chief Officer for Public Health and Environmental Hazards, or designee, with close collaboration with the Office of Patient Care Services’ Chief Consultant, Primary Care, or the Chief Consultant for Pharmacy Benefits Management, as appropriate to the particular event.
(b) The board is convened at the request of the Deputy Under Secretary for Health for Operations and Management as needed. The Chief Officer for Public Health and Environmental Hazards is responsible for leading, organizing, and implementing any required VHA “lookback” program performed as part of, or following, a large-scale disclosure to patients.
(2) The CRAAB is responsible for:
(a) Conducting, for each request by the Deputy Under Secretary for Health for Operations and Management, a decision process based on organizational, ethical, and clinical risk considerations outlined in Attachment C.
(b) Establishing and communicating the evaluation factors to be used to determine population risk. NOTE: One example for the Clinical Risk Assessment Advisory Board to use as a starting point is provided in the Matrix and Flow Chart in Attachment C. Depending on the event, factors may include evaluation and estimation of:
1. The population at risk of the adverse event or a potential adverse event,
2. The potential severity of the outcomes,
3. The probability of these outcomes, and
4. How to integrate other factors germane to the impact on the population at risk.
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(c) Providing recommendations and documentation to the Principal Deputy Under Secretary for Health regarding the necessity of a large scale disclosure.
(d) Providing recommendations and documentation to the Principal Deputy Under Secretary for Health, if a large scale disclosure is approved, on how it should conducted and serve in an advisory role to the individual or group assigned to conduct the actual disclosure.
g. The Principal Deputy Under Secretary for Health. The Principal Deputy Under Secretary for Health makes the decision concerning large scale adverse event disclosures and communicates that decision to the Deputy Under Secretary for Health for Operations and Management with a copy to the Chair, CRAAB.
5. REFERENCES
a. American Society for Healthcare Risk Management of the American Hospital Association. “Disclosure of Unanticipated Events: The Next Step In Better Communication With Patients,” May 2003.
b. American Society for Healthcare Risk Management of the American Hospital Association. “Disclosure of Unanticipated Events: Creating An Effective Patient Communication Policy,” November 2003.
c. American Society for Healthcare Risk Management of the American Hospital Association. “Communication: What Works Now and What Can Work Even Better,” February 2004.
d. JCAHO Accreditation Manual for Hospitals, Ethics, Rights and Responsibilities, RI 2.90, 2006.
e. JCAHO Accreditation Manual for Hospitals, Leadership Standards, LD 4.40, 2006.
f. VA Handbook 6300.4, Procedures for Processing Requests for Records Subject to the Privacy Act.
g. VHA Handbook 1050.01.
h VHA Handbook 1004.1.
j. VHA Handbook 1605.1.
k. VHA National Ethics Committee Report, "Disclosing Adverse Events to Patients," March 2003. http://vaww1.va.gov/vhaethics/download/AdverseEventsReport.doc
6. FOLLOW-UP RESPONSIBILITY: The Deputy Under Secretary for Health for Operations and Management (10N), the National Center for Ethics in Health Care (10E), and Patient Care Services (11) are jointly responsible for this Directive. Questions about operational issues may
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be addressed to (202) 273-5852. Questions about the ethical content may be addressed to (202) 501-0364.
7. RESCISSION: VHA Directive 2005-049 is rescinded. This Directive expires January 31, 2013.
Michael J. Kussman, MD, MS, MACP
Under Secretary for Health
DISTRIBUTION:
CO:
E-mailed 1/23/08
FLD:
VISN, MA, DO, OC, OCRO, and 200 E-mailed 1/23/08
VHA DIRECTIVE 2008 -002
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ATTACHMENT A
WHAT ADVERSE EVENTS WARRANT DISCLOSURE?
WHEN SHOULD DISCLOSURE OF AN ADVERSE EVENT OCCUR?
HOW SHOULD ADVERSE EVENTS BE COMMUNICATED?
1. WHAT ADVERSE EVENTS WARRANT DISCLOSURE?
a. Adverse events are untoward incidents, therapeutic misadventures, iatrogenic injuries, or other adverse occurrences directly associated with care or services provided within the jurisdiction of a medical center, outpatient clinic, or other Veterans Health Administration (VHA) facility. For an adverse event that has the apparent potential to affect, or may have already affected patients at more than one VHA field facility, or affects a significant number of patients, or involves significant actual or potential severity the process for large scale disclosure must be followed. The process is based on ethical and clinical considerations as outlined in Attachment C.
b. For all other adverse events, patients or their personal representatives must be informed of the occurrence of any adverse event that has resulted in, or can be expected to result in, harm to the patient, including the following:
(1) Adverse events that have had or are expected to have a clinical effect on the patient that is perceptible to either the patient or the health care team. For example, if a patient is mistakenly given a dose of furosemide (a diuretic that dramatically increases urine output), disclosure is required because a perceptible effect is anticipated to occur.
(2) Adverse events that necessitate a change in the patient’s care. For example, a medication error that necessitates extra blood tests, extra hospital days, or follow-up visits that would otherwise not be required, or a surgical procedure that necessitates further (corrective) surgery.
(3) Adverse events with a known risk of serious future health consequences, even if the likelihood of that risk is extremely small. For example, a known, accidental exposure of a patient to ionizing radiation, a toxin, an organism, or infectious entity associated with a rare, but recognized serious short-term or long-term effect (e.g., bloodborne pathogen infection or increased incidence of cancer). In some cases, however, no definite exposure of this type can be determined. Only an increased risk of exposure is known or thought to exist. In such cases, disclosure should be decided on a case by case basis considering the best interests of the patient, weighing the risks and benefits of disclosure relative to the probability of serious future health consequences.
(4) Adverse events that require providing a treatment or procedure without the patient’s consent. For example, if an adverse event occurs while a patient is under anesthesia, necessitating a deviation from the procedure the patient expected, the adverse event needs to be disclosed. Patients have a fundamental right to be informed about what is done to them and why.
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c. Disclosure of other adverse events is optional and at the discretion of the providers involved. Cases need to be considered individually and in relation to the specific circumstances.
d. Disclosure of “close calls” to patients is also discretionary, but is advisable at times, such as when the patient or family becomes aware that something out of the ordinary has occurred. For example, a nurse sets a patient up for a blood transfusion and, discovering that the patient is about to receive the wrong unit of blood, abruptly stops the transfusion just before the blood enters the patient’s vein. The patient deserves an explanation, even if this is not considered a clinical disclosure of adverse events. NOTE: Although the disclosure of a close call to the patient is optional, reporting it is required under VHA Handbook 1050.01
2. WHEN SHOULD DISCLOSURE OF AN ADVERSE EVENT OCCUR?
Optimal timing of disclosure of adverse events varies with the specific circumstances of the case. If a patient needs urgent treatment to minimize injuries resulting from an adverse event, clinical disclosure must occur quickly. If immediate corrective action is not required, disclosure may be delayed, but only long enough to give staff members time to collect preliminary information and plan the best way to disclose. For patients who are aware of, or suspect, an adverse event, more time prior to disclosure may increase the chance for patients to have anxiety and suspicion, and decrease the patient’s trust of VHA health care providers and management.
a. Clinical disclosure of an adverse event must occur within 24 hours of a practitioner’s discovery of the adverse event if adequate information is available.
b. Institutional disclosure of an adverse event must take place as soon as possible (generally within 24 hours, but no more than 72 hours if adequate information is available) after a practitioner’s discovery of the adverse event.
c. For large scale adverse event disclosure, adequate time is necessary for evaluation and planning in collaboration with the Principal Deputy Under Secretary for Health, Deputy Under Secretary for Health for Operations and Management, and the Clinical Risk Assessment Advisory Board (CRAAB). In these cases the disclosure process should start within 30 days after the Chairperson, Clinical Risk Assessment Advisory Board has accepted the adverse event(s) for review, unless extension is granted by the Principal Deputy Under Secretary for Health.
3. HOW SHOULD ADVERSE EVENTS BE COMMUNICATED?
a. Clinical Disclosure of Adverse Events. In general, communication about an adverse event done as a clinical disclosure of an adverse events proceeds as follows:
(1) One or more members of the clinical team provides preliminary factual information to the extent it is known, expresses concern for the patient’s welfare, and reassures the patient or
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personal representative that steps are being taken to investigate the situation, remedy any injury, and prevent further harm.
(2) A social worker, chaplain, patient advocate, or other staff may be present to help the patient or personal representative cope with the news and to offer support, if needed.
(3) The patient’s treating practitioner is responsible for determining who shall communicate this information. Such disclosure needs to occur in an appropriate setting and be done face-to-face. NOTE: The location needs to be a quiet, private place and adequate time needs to be set aside, with no interruptions.
b. Institutional Disclosure of Adverse Events. Sometimes, given the nature, likelihood, and severity of injury, and the degree of risk for legal liability, there is a need for institutional disclosure of adverse events either instead of, or in addition to, clinical disclosure. Like clinical disclosure, institutional disclosure needs to occur in an appropriate setting and be done face-to-face. The location needs to be a quiet, private place and adequate time needs to be set aside, with no interruptions. Institutional disclosure includes the following elements:
(1) Institutional Leaders (e.g., the Nurse Executive, Chief of Staff or facility Director) invite the patient or personal representative to meet for an Institutional Disclosure of Adverse Event Conference. Institutional leaders may only invite the personal representative if he or she is involved in the patient’s care (and the patient does not object), or is acting as a personal representative as outlined in VHA Handbook 1605.1. NOTE: The facility Risk Manager or Patient Safety Manager, treating physician, or other VHA personnel deemed appropriate, may be included in this conference at the discretion of facility leadership.
(2) Institutional disclosure of adverse events should not take place until organizational leaders, including, as appropriate, the facility Director, Chief of Staff, Nurse Executive and members of the treatment team, have conferred with Regional Counsel and addressed what is to be communicated, by whom, and how.
(3) Any request by a patient or personal representative to bring an attorney must be honored, but may influence whether providers will participate.
(4) The Risk Manager or Patient Safety Manager or organizational leaders need to engage in ongoing communication with the patient or personal representative to keep them apprised, as appropriate, of information that emerges from investigation of the facts related to the adverse event. Documents considered confidential under Title 38 United States Code (U.S.C.) Section 5705, such as root cause analyses and peer reviews, cannot be disclosed to attorneys, patients, or the personal representatives of patients, and may only be used for patient safety and quality improvement.
(5) If the patient is not capable of understanding the disclosure of adverse event, and the patient does not have a personal representative as defined in VHA Handbook 1605.1, the facility may make the institutional disclosure to a family member involved in the patient’s care. Consult the facility’s or VHA’s Privacy Office for additional guidance.
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(6) Documentation such as reports of contact or incident reports may be kept in some other file at the facility’s discretion and entitled “Adverse Event and Close Call Report.” This information must not be retrieved by patient identifier and must be identified by a case number.
NOTE: The Adverse Event and Close Call Report is protected under 38 U.S.C. Section 5705.
(7) Documenting information in records protected under 38 U.S.C. Section 5705 is never to be done to shield information to which a patient is entitled. Likewise, the fact that information may be documented in records protected under 38 U.S.C. Section 5705 does not mean that the identical information, documented in CPRS, cannot be retrieved by patients.
(8) Institutional disclosure must be documented using the template in Attachment B.
(9) Institutional disclosure of adverse events must include:
(a) An apology including a complete explanation of the facts.
(b) An outline of treatment options.
(c) Arrangements for a second opinion, additional monitoring, expediting clinical consultations, bereavement support, or whatever might be appropriate depending on the adverse event.
(d) Notification that the patient or personal representative has the option of obtaining outside legal advice for further guidance.
(10) After complete investigation of the facts, the veteran patient or personal representative is to be given information about compensation under 38 U.S.C. Section 1151 and the Federal Tort Claims Act claims processes, including information about procedures available to request compensation and where and how to obtain assistance in filing forms. In the event that the investigation is not complete, information about compensation may be given based on the current understanding of the facts or information may be deferred until the investigation is competed. There should be no assurance that compensation will be granted, as the adverse event may not give rise to and meet legal criteria for compensation under 38 U.S.C. Section 1151 and the Federal Tort Claims Act.
(11) If a patient or the patient's personal representative asks whether an investigation will be conducted and whether the patient or the patient's personal representative will be told of the results of an investigation, the patient or personal representative is to be informed that only the results of an administrative board of investigation (AIB) may be released.
c. Large Scale Disclosure of Adverse Events.
(1) Large scale disclosure will be done in alignment with the plan for disclosure as developed by the Department of Veterans Affairs (VA) CRAAB with adequate time for
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evaluation and planning at the VA Central Office level. Depending on the nature of the event, disclosure to veterans may entail any or all of the following:
(a) Institutional disclosure to affected veterans.
(b) Notification by mail or telephone to potentially affected veterans.
(c) Notification to facilities for required follow up with potentially affected veterans.
(2) In addition, the disclosure plan may include public affairs strategies such as announcement through the media, information and support to clinical providers, and/or establishment of call centers or web sites.
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ATTACHMENT B
DISCLOSURE OF ADVERSE EVENT NOTE TEMPLATE
FOUND IN THE VETERANS HEALTH INFORMATION SYSTEM AND TECHNOLOGY ARCHITECTURE (VISTA) COMPUTERIZED PATIENT
RECORD SYSTEM
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ATTACHMENT C
LEADERSHIP DECISION PROCESS FOR
LARGE SCALE DISCLOSURE OF ADVERSE EVENTS
NOTE: This guidance is based on the Veterans Health Administration (VHA), VHA National Center for Ethics Report on Ethical Leadership: Fostering an Ethical Environment and Culture. 2007, p. 34.
1. Within the Veterans Health Administration (VHA), there is a presumptive obligation to disclose adverse events that cause harm to patients. However, in the case of an adverse event that has the potential to affect dozens or even thousands of patients, a public health response also requires a determination of the probability and magnitude of harm resulting from the adverse event as well as a weighing of additional factors, including, but not limited to salient ethical principles; risk of harm to veterans and identifiable third parties; benefit and burden of disclosure to veterans including medical, psychological, social or economic, impact on the institution’s perceived integrity and its capacity to provide care and treatment for all veterans; as well as applicable policy and relevant precedent. The Clinical Risk Assessment Advisory Board (CRAAB) needs to include the following considerations in its decision process:
1. DO WE HAVE ALL THE IMPORTANT FACTS RELEVANT TO THE DECISION?
a. How many veterans exposed or potentially exposed?
b. What is the probability that a given veteran was exposed to the adverse event?
c. What is the probability that the adverse event will cause a particular veteran harm?
d. What is the nature of the potential harm?
e. What is the expected magnitude of the harm?
f. What is the expected duration of the harm?
g. Is there treatment available to prevent or ameliorate the harm?
h. Does the harm have the potential to extend beyond the identified patient, to third parties and what is the probability that the extension of harm would occur?
NOTE: On a case-by-case basis, additional questions may be relevant. Consult the matrix and flow chart in this Attachment C to analyze relevant facts.
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2. HAVE WE INVOLVED EVERYONE WHO SHOULD BE PART OF THIS DECISION?
a. Membership in the CRAAB includes the following offices:
(1) Deputy Under Secretary for Health for Operations and Management;
(2) Office of Patient Care Services (e.g., Infectious Diseases Program Office and/or Primary Care or Pharmacy Benefits Management, as appropriate to the event);
(3) National Center for Ethics in Health Care;
(4) National Center for Patient Safety;
(5) Office of Public Health and Environmental Hazards;
(6) Office of Nursing Services; and
(7) Office of Quality and Performance.
NOTE: Consideration is to be given on a case-by-case basis to including other individuals or groups to ensure that the perspectives of all relevant subject matter experts and stakeholders affected by the decision have an opportunity for input.
3. DOES THIS DECISION REFLECT ORGANIZATIONAL, PROFESSIONAL, AND SOCIAL VALUES?
a. Does the decision reflect VHA core values such as trust, respect, excellence and commitment? For example, would the decision inspire a high degree of confidence in our honesty, integrity, reliability and sincere good intent? Would the decision demonstrate an understanding of, sensitivity to, and concern for each person’s individuality and importance? Would the decision indicate that we are taking responsibility for our collective action? That we are preserving the organization’s reputation and exercising appropriate stewardship of public resources?
b. Does the decision reflect values central to health care provider professionalism? For example, does the decision hold in high regard the dignity and worth of our patients?
c. Does the decision reflect values central to public health practice? For example, does the decision reflect and make use of the best epidemiological evidence to improve population health?
NOTE: On a case-by-case basis, additional values may be relevant.
VHA DIRECTIVE 2008-002
January 18, 2008
C-3
4. DO THE LIKELY BENEFITS OF THE DECISION OUTWEIGH ANY POTENTIAL HARMS?
Although it is difficult to weigh all benefits and harms, situations prompting a decision whether to conduct large scale disclosure of adverse events likely involves the following considerations:
a. Are there medical, social, psychological, or economic benefits or burdens to the veterans, resulting from the disclosure itself?
b. What is the burden of disclosure to the institution, focusing principally on the institution’s capacity to provide health care to other veterans?
c. What is the potential harm to the institution of both disclosure and non-disclosure in the level of trust that veterans and Congress would have in VHA?
NOTE: On a case-by-case basis, additional questions may be relevant.
5. WILL THIS DECISION KEEP THE PROBLEM FROM RECURRING OR ESTABLISH A GOOD PRECEDENT?
a. Is this a good model for how similar questions should be handled in the future?
b. Has the decision process been followed and documented in a way that can be easily referenced for any similar future cases?
6. HOW WOULD THIS DECISION LOOK TO SOMEONE OUTSIDE THE ORGANIZATION?
a. Does this decision reflect similar decisions by other large health care systems?
b. Will the decision be understood and accepted by veterans, the public?
c. Was the process used to make the decision systematic, examining the question from all angles?
d. Was the process used to make the decision transparent, that is, was the reasoning made clear to all involved?
2. In any particular large scale case, the answers to these questions should assist in the assessment of the benefits and burdens of disclosure. After these issues are considered, the Matrix and Flow Charts in Attachments D and E are examples of aids for the Clinical Risk Assessment Advisory Board to use as a starting point for making disclosure decisions for large scale adverse events. Based on the nature of the adverse event, the Clinical Risk Assessment Advisory Board may also seek other sources or develop additional aids to assist with this patient centered decision making. NOTE: The content in both the Matrix and Flow Chart is the same, but is presented in two different formats for the reader’s benefit.
VHA DIRECTIVE 2008-002
January 18, 2008
D-1
ATTACHEMENT D
CLINICAL CONSIDERATIONS
The following Matrix is an example of an aid for the Clinical Risk Assessment Advisory Board (CRABB) to use as a starting point for making disclosure decisions for large scale adverse events. Based on the nature of the adverse event, the Clinical Risk Assessment Advisory Board may also seek out other sources and/or develop additional aids to assist with this patient-centered decision making.
MATRIX TO AID IN ADVERSE EVENT DISCLOSURE DECISIONS FOR LARGE SCALE EVENTS
Severity
Effect Would be Clinically Significant, i.e., Clinically Significant means a condition that causes harm or illness and/or that requires testing, monitoring, or short-term or long-term treatment.
Effect Would Not be Clinically Significant, i.e., Not Clinically Significant means a condition that causes no perceptible harm or illness and does not require any testing, monitoring, or short-term or long-term treatment.
Probability
The probability is determined based on a review of the literature, or, if inadequate literature, by the expert opinion of the Department of Veterans Affairs (VA) CRAAB. Previous VA and non-VA experience with similar adverse events or exposures may be appropriate for consideration, even if not available in the published literature.
Less than one patient in 10,000 patients subject to the event or exposure are expected to have any short-term or long-term health effect that would require any treatment or cause serious illness if untreated.*
No presumption in favor of disclosure of event or exposure; however disclosure or notification may be warranted on the basis of ethical, clinical, or other considerations.
No requirement to disclose event or exposure
VHA DIRECTIVE 2008-002
January 18, 2008
D-2
Clinically Significant
Not Clinically Significant
Probability: The probability will be determined based on a review of the literature, or, if inadequate literature, by the expert opinion of the VA CRAAB. Previous VA and non-VA experience with similar adverse events or exposures may be appropriate for consideration, even if not available in the published literature.
One patient or more in 10,000 patients subject to the event or exposure is expected to have a short-term or long-term health effect that would require treatment or cause serious illness if untreated.
Presumption in favor of disclosure of event or exposure; however, a decision not to disclose or notify may be warranted on the basis of ethical, clinical, or other considerations.
No requirement to disclose event or exposure
VHA DIRECTIVE 20087-002
January 18, 2008
E-1
ATTACHMENT E
FLOW CHART TO AID IN ADVERSE EVENT DISCLOSURE DECISIONS FOR LARGE SCALE EVENTS
The following Flow Chart is an example of an aid for the Clinical Risk Assessment Advisory Board to use as a starting point for making disclosure decisions for large scale adverse events. Based on the nature of the adverse event, the Clinical Risk Assessment Advisory Board may also seek out other sources and/or develop additional aids to assist with this patient-centered decision making.
*Clinically Significant: A condition causes harm or illness and/or requires testing, monitoring, or short-term or long-term treatment.
+Not Clinically Significant: A condition that causes no perceptible harm or illness and requires no testing, monitoring, or short-term or long-term treatment.
† Probability The probability is determined based on a review of the literature, or, if inadequate literature, by the expert opinion of the VA Central Office Clinical Risk Assessment Advisory Board. Previous VA and non-VA experience with similar adverse events or exposures may be appropriate for consideration, even if not available in the published literature.
VHA DIRECTIVE 2008-002
January 18, 2008
E-2
What is the estimated probability, or the projected rate of an adverse event in the patient population?
No requirement to disclose event or exposure
No*
Yes+
Fewer than one patient in 10,000†
One or more patient(s) in 10,000†
No presumption in favor of disclosure of event or exposure; however, disclosure or notification may be warranted on the basis of ethical, clinical, or other considerations.
Presumption in favor of disclosure of event or exposure; however, a decision not to disclose or notify may be warranted on the basis of ethical, clinical, or other considerations
Is the event or exposure clinically significant?*

VA's Directive 2009-004, Reprocessing Reuseable Medical Equipment

Department of Veterans Affairs VHA DIRECTIVE 2009-004
Veterans Health Administration
Washington, DC 20420 February 9, 2009
USE AND REPROCESSING OF REUSABLE MEDICAL EQUIPMENT (RME) IN VETERANS HEALTH ADMINISTRATION FACILITIES
1. PURPOSE: This Veterans Health Administration (VHA) Directive provides procedures for the design and implementation of a systematic approach for the set up, proper use, reprocessing, and maintenance of all reusable medical equipment (RME) used in VHA facilities.
2. BACKGROUND
a. The safe performance of procedures involving RME requires a systematic process including, but not limited to: initial training of personnel, proper setup, use, and reprocessing for each occurrence; an annual validation of the competency of the staff involved; and quality oversight. The details for each of these steps can effectively be documented in a locally-established standard operating procedure (SOP).
b. Multiple professional disciplines and many different types of RME used across a spectrum of clinical services are involved. For this reason, clear lines of responsibility and accountability must be established to ensure proper outcomes of the identified procedures, SOPs, competency requirements, quality monitoring processes, and clear identification of oversight and accountability for every step and handoff in the process.
c. Definitions
(1) Reusable Medical Equipment (RME). RME is any medical equipment designed by the manufacturer to be reused for multiple patients. All RME must be accompanied by reprocessing instructions provided by the manufacturer.
(2) Standard Operating Procedure (SOP). An SOP is a document detailing all steps and activities of a process or procedure that is dated and signed by an approving official.
(3) Reprocessing. Reprocessing is the cleaning, disinfection, sterilization, and preparation of equipment to full readiness for its subsequent use. This can occur in part or in whole, either inside or outside of Supply, Processing, and Distribution (SPD).
(4) Set-up. Set-up is the process of assembling the RME in preparation for a procedure in accordance with manufacturer’s instructions.
(5) Competency. Competency is the assurance that an individual has received the appropriate training and has demonstrated an achieved skill level required to independently and appropriately perform an assigned task or responsibility.
(6) Quality Assurance. Quality assurance is the process for continuously monitoring the processes and outcomes of a pre-determined procedure to ensure safe patient care.
THIS VHA DIRECTIVE EXPIRES FEBRUARY 28, 2014
VHA DIRECTIVE 2009-004
February 9, 2009
2
(7) Maintenance. Maintenance includes the actions taken, in accordance with manufacturer’s instructions, to preserve the optimal and safe usefulness of medical equipment and its associated accessories.
3. POLICY: It is VHA policy that systematic and local standard processes are developed in compliance with manufacturer’s instruction, infection prevention and control principles, and effectively communicated and deployed to staff wherever procedures using RME are performed.
4. ACTION
a. Infectious Diseases Program of the Office of Patient Care Services. The National Director of the Infectious Diseases Program, Office of Patient Care Services, is responsible for:
(1) The development of national policy pertaining to the reprocessing of RME, and
(2) Liaising with the Networks and the Office of the Deputy Under Secretary for Health for Operations and Management.
b. Network Director. The Network Director is responsible for:
(1) Establishing a continuing oversight function, coordinated by the Network Chief Medical Officer, using subject matter experts.
(2) Conducting, at least annually, unannounced site audits of each facility in their Network, that must include.
(a) Ensuring that RME systematic processes are fully implemented and executed at all facilities.
(b) Ensuring that appropriate training is provided and completed for all users of RME prior to initial use.
(c) Ensuring competencies are documented and SOPs exist for each RME and are current and correct based upon manufacturer’s written instructions.
(d) Ensuring identification of accountability, responsibility and documented performance at each step in the process.
(e) Ensuring a quality assurance process is established.
(f) Ensuring assigned staff are collecting data, conducting an analyses, and taking required actions to ensure safe and effective use of RME.
(3) Ensuring that local standards and systematic RME processes are established and documented in a SOP within any medical facilities under the purview of VHA that perform procedures utilizing RME.
VHA DIRECTIVE 2009-004
February 9, 2009
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c. Facility Director. The Facility Director is responsible for ensuring:
(1) All personnel that are in any way involved in the use and reprocessing of RME have documented training on the setup, use, reprocessing, and maintenance of the specific equipment leading to initial competency and validation of that competency on an annual basis.
(a) The duties and expected outcomes must be clearly evident in the staff’s position description and functional statements and must be identified as a critical element in their annual performance standards.
(b) The language and process for validation is a collaborative effort with the standards being established by the highest level of authority within the medical center on each of the following elements: reprocessing, disinfection, sterilization, maintenance and incorporation of manufacturer’s instructions.
(2) That device-specific standards and systematic RME processes are established and documented in a SOP that includes at least the following elements:
(a) Defined process and accountability for performing and documenting initial competency for staff, including required training to be accomplished prior to initial use.
(b) Process and accountability for validating continued staff competency at least annually.
(c) Process and accountability for setup of RME equipment based on manufacturer’s instructions.
(d) Process and accountability for reprocessing and maintenance of equipment and supplies utilized in RME procedures.
(e) Organizational structure that includes an interdisciplinary approach to monitoring the compliance with the established process(es) and documents outcomes related to the defined process(es).
(f) Interdisciplinary approach requires participation by Chief, SPD; a representative of Quality and Risk Management; a Nursing Service representative; an Infection Control Professional; a Patient Safety manager; and a representative of Bio-Medical Engineering.
(g) Reporting required to the Executive Committee of the Medical Staff, including, but not limited to: validation of initial and on-going competency of staff, results of compliance with established SOPs, results of infection prevention and control monitoring, and risk management related activities.
(3) That device-specific SOPs for set up and reprocessing of RME are posted in any area where these devices are reprocessed.
VHA DIRECTIVE 2009-004
February 9, 2009
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d. Associate Medical Center Director, Nurse Executive, or Chief of Staff. The Associate Medical Center Director, Nurse Executive, or Chief of Staff is responsible for execution of the defined process(es), including, but not limited to:
(1) Ensuring that all staff involved in RME processes have clearly defined responsibilities within their position descriptions or functional statements.
(2) Ensuring that all staff involved in RME processes have clearly-defined performance standards that are identified as critical elements in performance appraisals.
(3) Ensuring implementation of a systematic approach to the performance of procedures involving RME throughout the facility and associated sites.
(4) Ensuring collaboration of all organizational structures within the facility to achieve a comprehensive monitoring system that supports safety and quality in the performance of procedures involving RME.
e. Chief, SPD. The Chief, SPD, is responsible for:
(1) Technical oversight of all reprocessing of RME and equipment used in reprocessing wherever such reprocessing occurs within the facility, regardless of organizational alignment.
(2) Development, administration, and validation of initial and annual competencies for staff performing reprocessing of RME and for all personnel involved in using the reprocessing equipment.
(3) Ensuring all functions of SPD, regardless of organizational alignment, are functioning effectively; this includes: decontamination, preparation, case cart and distribution, etc.
5. REFERENCE
a. Centers for Disease Control and Prevention, Rutala, William A., Weber, David J. and the Healthcare Infection Control Practices Advisory Committee. Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008.
b. VA Handbook 7176, Supply, Processing, and Distribution (SPD), Operational Requirements.
6. FOLLOW UP RESPONSIBILITY: The Office of Patient Care Services (11) is responsible for the contents of this Directive. Questions regarding the administrative components may be referred to the Chief Consultant Medical Surgical Services (111) at (202) 461-7120. Questions related to the technical components of this Directive may be referred to the Infectious Diseases Program Office at (513) 475-6398.
VHA DIRECTIVE 2009-004
February 9, 2009
5
7. RECISIONS: None. This VHA Directive expires February 28, 2014.
Michael J. Kussman, MD, MS, MACP
Under Secretary for Health
DISTRIBUTION:
CO:
E-mailed 2/9/2009
FLD:
VISN, MA, DO, OC, OCRO, and 200 – E-mail 2/9/2009

VA's Directive 2010-012, TBI Secreening and Evaluation

Department of Veterans Affairs
VHA DIRECTIVE 2010-012
Veterans Health Administration
Washington, DC 20420
March 8, 2010
SCREENING AND EVALUATION OF POSSIBLE TRAUMATIC BRAIN INJURY IN
OPERATION ENDURING FREEDOM (OEF) AND OPERATION IRAQI
FREEDOM (OIF) VETERANS
1. PURPOSE: This Veterans Health Administration (VHA) Directive updates policies and procedures for screening and evaluation of possible traumatic brain injury (TBI) in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans.
2. BACKGROUND
a. TBI is a common injury found in servicemembers serving in OEF and OIF. Details on the screening and management of TBI can be found in the Employee Education System Veterans Health Initiative (VHI) module (see paragraph 5). As occurrences of this condition in OEF and OIF Veterans increased, screening for possible TBI in OEF and OIF Veterans could contribute to ensuring that individuals with TBI are identified and treated.
b. In response to this need, VHA established a task force including members with expertise in Physical Medicine and Rehabilitation, Neurology, Psychiatry, Psychology, Primary Care, Prevention, and Medical Informatics to develop a screening tool and evaluation protocol. Although TBI is a significant public health problem, currently there are no validated screening instruments accepted for use in clinical practice. Therefore, the task force reviewed existing literature on screening for TBI, examined the efforts of individual military medical treatment facilities (MMTF) and Department of Veterans Affairs (VA) Medical Centers that had implemented TBI screening locally, consulted with the Defense and Veterans Brain Injury Center (DVBIC), and considered data on the natural history of TBI. Based on these efforts, the task force developed a screening instrument to assist in identifying OEF and OIF Veterans who may be suffering from TBI, and a protocol for further evaluation and treatment of those whose screening results are positive for possible TBI.
c. A national clinical reminder, VA-TBI Screening, was built incorporating this screening instrument. This reminder has the following elements:
(1) The first step of the reminder is to identify possible OEF and OIF participants based on whether date of separation from military duty or active duty status occurred after
September 11, 2001.
(a) Similar to the "OEF/OIF Post-Deployment Screening Reminder," the initial questions address location of deployment.
(b) The definition of an OEF or OIF participant is the same used for the “OEF/OIF Post-Deployment Screen," which includes service in Afghanistan, Georgia, Kyrgyzstan, Pakistan,
THIS VHA DIRECTIVE EXPIRES MARCH 31, 2015
VHA DIRECTIVE 2010-012
March 8, 2010
2
Tajikistan, Uzbekistan, or the Philippines. OIF participation includes service in Iraq, Kuwait, Saudi Arabia, or Turkey.
(c) The screening is done once for all individuals who report deployment to OEF and OIF Theaters, and is to be repeated if the date of separation has changed due to repeat deployment. The reminder recognizes if screening was completed prior to the most recent date of separation.
(2) The reminder then asks whether the patient has already been diagnosed as having TBI during OEF or OIF deployment. Positive answers may be based on patient or caregiver self-report or health records from VA or non-VA sources. Positive answers lead to an option to order a referral for follow-up if the patient does not have current follow-up and wants assistance.
(3) For those who confirm OEF or OIF deployment and do not have a prior diagnosis of TBI, the instrument proceeds using four sequential sets of questions.
(a) The four sections are:
1. Events that may increase the risk of TBI.
2. Immediate symptoms following the event.
3. New or worsening symptoms following the event.
4. Current symptoms.
(b) If a person responds negatively to any of the sets of questions, the screen is negative and the reminder is completed. If the patient responds positively to one or more possible answers in a section, the next section opens in the reminder to continue the screening process.
(4) If a person responds positively to one or more questions in each of the four sections, the screen is positive, the clinician discusses the results of the screen with the patient, and arrangements for further evaluation are offered. The reminder prompts the user to place a consultation for further evaluation or documents refusal.
d. Not all patients who screen positive have TBI. It is possible to respond positively to all four sections due to the presence of other conditions, such as Post Traumatic Stress Disorder (PTSD), cervico-cranial injury with headaches, or inner ear injury. Therefore, it is critical that patients not be labeled with the diagnosis of TBI on the basis of a positive screening test.
Patients need to be referred for a comprehensive evaluation to substantiate the diagnosis.
e. The VHA task force has developed a defined protocol for completing the additional evaluation by a specialized team. The Comprehensive TBI Evaluation is a comprehensive evaluation which includes the origin or etiology of the patient’s injury, assessment for neurobehavioral symptoms (using the 22-question Neurobehavioral Symptom Inventory), a targeted physical examination, and a follow up treatment plan. An electronic template for documentation of this evaluation has been developed and deployed. The diagnostic conclusion
VHA DIRECTIVE 2010-012
March 8, 2010
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regarding the occurrence of a TBI must be documented using this template. All TBI evaluations must be completed using the Comprehensive TBI Evaluation template. This application is hosted and supported by the VHA Support Service Center (VSSC) and is accessible using the Computerized Patient Record System (CPRS) Tools menu. NOTE: Reference documentation, including instructions for installing the template are available at http://vaww.rehab.va.gov/PMR/Comprehensive_TBI_Evaluation.asp. NOTE: This is an internal Web site and is not available to the public.
(1) The treatment algorithm available through VA's Web site at: http://vaww.rehab.va.gov/PMR/Comprehensive_TBI_Evaluation.asp provides guidance on physical examination, diagnostic testing, and recommendations for initial treatment interventions and referral pathways for persistent symptoms. NOTE: This is an internal Web site and is not available to the public.
(2) It is possible that patients may have co-existing diagnoses, such as PTSD and TBI, and these must be appropriately evaluated. Given the expertise required to establish a diagnosis of TBI and implement appropriate treatment, the protocol must be completed by Level II Polytrauma Network Sites (PNSs) or Level III Polytrauma Support Clinic Teams (PSCT) existing within the VHA Polytrauma System of Care (see Attachment A). If there is no Level II PNS or Level III PSCT at the medical center, the medical center has the option of determining an alternate plan and team that meets the intent of this Directive. This may include having the evaluation completed by a specialist with an appropriate background and skills, such as a physiatrist, neurologist, or neuropsychiatrist who has also had training in the evaluation protocol and in directing an interdisciplinary rehabilitation treatment team. Alternate plans are to be reviewed with the Veterans Integrated Service Network (VISN) Chief Medical Officer (CMO) and the national Director of Physical Medicine and Rehabilitation.
f. Between 24 and 59 percent of patients with traumatic spinal cord injury (SCI) have a concomitant TBI as reported in literature. The SCI system of care has the extensive multidisciplinary expertise needed to provide the required evaluation and care. TBI screening and evaluation are handled by the SCI team for patients followed in the SCI system of care and the initial treatment is provided by SCI Center personnel.
3. POLICY: It is VHA policy that all OEF and OIF Veterans receiving medical care within VHA must be screened for possible TBI; those Veterans who, on the basis of the screening may have TBI, must be offered further evaluation and treatment by clinicians with expertise in the area of TBI.
4. ACTION
a. National Director for Primary Care. The National Director for Primary Care is responsible for ensuring that:
(1) Screen captures and training material for the current version of the VA TBI Screening reminder are posted at http://vista.med.va.gov/reminders/index.html.
VHA DIRECTIVE 2010-012
March 8, 2010
4
(2) The reminder is kept up to date and modified, as needed, in the face of advancing clinical knowledge. NOTE: Any updates in the reminder must be implemented using a national Information Technology (IT) patch.
b. National Director for Physical Medicine and Rehabilitation. The National Director for Physical Medicine and Rehabilitation is responsible for:
(1) Maintaining a defined protocol for the comprehensive Second Level Evaluation of those who might have TBI, based on responses to screening. This protocol must:
(a) Include initial treatment interventions, and
(b) Be posted at the Physical Medicine and Rehabilitation TBI Web site at: http://vaww.rehab.va.gov/PMR/TBI_Clinical_Reminder.asp. NOTE: This is an internal Web site and is not available to the public.
(2) Providing training materials in the protocol for Level II PNSs and Level III PSCT and any other specialists who will be completing the protocol.
(3) Working with each VISN CMO to develop clear referral protocols, identifying the Level II PNSs or Level III PSCT(s), and approving alternate plans and recommendations for other specialists, who are to complete the Second Level Evaluation for each VA medical center.
c. VISN Director. The VISN Director is responsible for ensuring that:
(1) The direction and standards to ensure that the screening and evaluation of possible TBI in OEF and OIF Veterans is fully implemented.
(2) Expectations are established and commitments reinforced at all levels of the
organization.
(3) Adequate resources are allocated for implementation.
(4) Performance for TBI screening program is monitored.
d. Chief Medical Officer (CMO). The CMO is responsible for:
(1) Working with the National Director for PM&R to develop clear referral protocols, and identifying the Level II PNSs or Level III PSCT(s), and approving alternate plans and recommendations for other specialists, who are to complete the Second Level Evaluation for each VA medical center.
(2) Ensuring that all clinical activities for utilizing the TBI Screening and Evaluation Tool meet or exceed the standards set by the VISN Director.
VHA DIRECTIVE 2010-012
March 8, 2010
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e. VISN Quality Management Officer (QMO). The VISN QMO is responsible for:
(1) Monitoring the effectiveness of the TBI Screening and Evaluation Tool as part of the VISN’s QM and PI program.
(2) Ensuring that “lessons learned” and “strong practices” are identified and communicated.
(3) Representing the interests of the VISN in all VHA Central Office interactions on Quality Management issues regarding the implementation of the TBI Screening and Evaluation Tool.
f. Veterans Integrated Service Network (VISN) Chief Information Officer (CIO)
(1) The VISN CIO is responsible for ensuring that all medical centers have installed patch PXRM*2.0*8, the VA TBI Screening clinical reminder and reminder dialog.
(2) The VISN CIO is responsible for ensuring that all medical centers install the current version of the Comprehensive TBI Evaluation. This application is hosted and supported by the VSSC and is accessible using the CPRS Tools menu. NOTE: Reference documentation, including instructions for installing the template is available at http://vaww.rehab.va.gov/PMR/TBI_Clinical_Reminder.asp. NOTE: This is an internal Web site and is not available to the public.
g. Facility Director. Each Facility Director is responsible for ensuring that:
(1) The National VHA TBI Screening clinical reminder is assigned at the “system” level, or “division” level at all divisions, in CPRS. It is to be available to all users and must be “locked” so that it is not removable by individual users.
(2) The reminder is completed for all OEF and OIF Veterans who present at the facility for medical care regardless of the reason for their visit (see Attachment B for a flow chart demonstrating the process).
(3) The patient with possible TBI is offered a comprehensive evaluation by a PNS or a PSCT polytrauma team. For sites that do not have a PNS or PSCT team and wish to complete the evaluation protocols locally, an alternate plan and team that meets the intent of this Directive, including other specialists such as physiatrists, neurologists, or neuropsychiatrists, must be identified to complete the evaluation protocols after completing training. NOTE: For patients in the SCI system of care, the evaluation protocol is done by a designated SCI team.
(4) The provider reviews all screens with the patient regardless of method of completion to ensure proper patient understanding and response accuracy. NOTE: The screen may be completed face-to-face, or in writing.
(5) When a Veteran screens positive for possible TBI, the findings are discussed with the patient by an appropriate clinical staff member and further evaluation is offered. Consultations for further evaluation must be submitted with agreement by the patient. The clinical staff
VHA DIRECTIVE 2010-012
March 8, 2010
6
member must document the discussion of screening results with the patient and any refusal of further evaluation by the patient within the progress note (using the clinical reminder dialog).
(6) A medical center service is clearly identified for initial management of the consults generated by positive screens. Generally this service is located at the facility. However, it is acceptable for the service to be located at another facility, such as one where the covering Level II PNSs or Level III PSCTs is located.
(7) The facility's alternate plan and team composition meets the intent of this Directive, if the facility is not a Level II PNS or Level III PSCT and the facility does not refer to a Level II PNS or Level III PSCT.
(8) Requests for alternate plans and team to complete the comprehensive evaluation and treatment are directed to the National Director for Physical Medicine and Rehabilitation through the VISN CMO.
(9) The identified service initiates contact with the referred patient within 5 working days to assist in arranging the recommended evaluation. NOTE: It is strongly recommended that, in addition to calling the Veteran by telephone, a letter is sent to the patient indicating that a consultation has been received, and provides information on how to schedule an appointment upon receipt of the letter to facilitate contact efforts.
(a) If the initial effort to contact the patient by telephone is unsuccessful, follow-up efforts must include at least two additional telephone calls within 14 days of the positive screen. Calls must be completed on different days of the week and different times of the day.
(b) If contact by phone is not successful after three attempts, a certified letter must be sent to the patient providing contact information should they desire to schedule an appointment. This letter must be sent within 14 days of the positive screen.
(c) These efforts and any refusals by patients to participate in the recommended evaluation must be documented on the consult request in the patient’s health record.
(10) The clinical team responsible for completing the evaluation documents any appointments that were cancelled by the patient or "no shows," and must document all attempts to reschedule the patient for completing the evaluation. If the patient cancels or is a "no show" for three appointments, the consultation can be closed out. Any consult closeouts must include a notation sent to the referring provider to resubmit a consultation to the team should the patient be interested in future evaluation services.
(11) The patient with possible TBI is seen for the Comprehensive TBI Evaluation within
30 days of the initial positive screen regardless of the facility or specialty team responsible for completing the evaluation. The Comprehensive TBI Evaluation includes: the origin or etiology of the patient’s injury, assessment for neurobehavioral symptoms (using the 22-question Neurobehavioral Symptom Inventory), a targeted physical examination, and a comprehensive follow up treatment plan. All TBI evaluations must be completed using the Comprehensive TBI
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March 8, 2010
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Evaluation template. This application is hosted and supported by VSSC and it is accessible using the CPRS Tools menu. NOTE: Reference documentation, including instructions for installing the template are available at http://vaww.rehab.va.gov/PMR/Comprehensive_TBI_Evaluation.asp. NOTE: This is an internal Web site and is not available to the public.
(12) All staff at the facility involved in completing the evaluation protocol have completed the recommended training on the evaluation protocol.
(13) VA and non-VA inter-facility transfers are timely and follow policy outlined in current VHA policy.
h. SCI Center Chief. Each SCI Center Chief is responsible for ensuring that their staff has been trained in completing the evaluation protocol and for making it available at their SCI Center.
5. REFERENCES: Veterans Health Initiative (VHI) teaching module, “Traumatic Brain Injury,” found at http://www.va.gov/vhi/.
6. FOLLOW-UP RESPONSIBILITY: The Chief Consultant for Primary Care (11PC) and Chief Consultant for Rehabilitation (117) are responsible for the contents of this Directive. Questions are referred to (202) 461-7444.
7. RECISSIONS: VHA Directive 2007-013, dated April 13, 2007, is rescinded. This VHA Directive expires March 31, 2015.
Robert A. Petzel, M.D.
Under Secretary for Health
DISTRIBUTION:
E-mailed to the VHA Publication Distribution List 3/2410
VHA DIRECTIVE 2010-012
March 8, 2010
A-1
ATTACHMENT A
VETERANS HEALTH ADMINISTRATION (VHA)
POLYTRAUMA SYSTEM OF CARE
1. Level I: Polytrauma Rehabilitation Centers
Four regional Polytrauma Rehabilitation Centers (PRC) provide acute comprehensive medical and rehabilitation care for the severely injured. They maintain a full team of dedicated rehabilitation professionals and consultants from other specialties related to polytrauma. These PRCs, serving as resources for other facilities and assisting in the development of care plans, are located in Richmond, VA; Tampa FL; Minneapolis, MN; and Palo Alto, CA.
2. Level II: Polytrauma Network Sites
Twenty one Polytrauma Network Sites (PNS) provide specialized, post-acute rehabilitation services in consultation with the PRCs in a setting appropriate to the needs of Veterans, service members, and families. There is one PNS in each of the twenty-one VHA Networks, including one at each of the four Level I PRC sites. Each PNS has a dedicated interdisciplinary team with specialized training, providing proactive case management for existing and emerging conditions, and identifying resources for Department of Veterans Affairs (VA) and non-VA care.
3. Level III: Polytrauma Support Clinic Teams
Polytrauma Support Clinic Teams (PSCT) are local teams of providers with rehabilitation expertise who deliver follow up services in consultation with regional and network specialists. They are located at many, but not all, Medical Centers that do not have a Level I or Level II center. PSCTs assist in the management of stable polytrauma sequelae through direct care, consultation, and the use of telerehabilitation technologies, as needed.
4. Level IV: Polytrauma Points of Contact
Polytrauma Points of Contact (PPOC) are present in facilities that do not have Level I, Level II, or Level III services. Facilities that do not have the necessary services to provide specialized care must have a designated PPOC to ensure that patients are referred to a facility capable of providing the Level of services required. PPOCs commonly refer to the PNS and PSCTs within their network.
VHA DIRECTIVE 2010-012
March 8, 2010
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ATTACHMENT B
FLOW CHART FOR SCREENING AND EVALUATION OF POSSIBLE TRAUMATIC BRAIN INJURY (TBI) IN OPERATION ENDURING FREEDOM (OEF) AND
OPERATION IRAQI FREEDOM (OIF) VETERANS
VHA DIRECTIVE 2010-009
March 8, 2010
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ATTACHMENT C
FREQUENTLY ASKED QUESTIONS REGARDING TRAUMATIC
BRAIN INJURY IN OPERATION ENDURING FREEDOM (OEF) AND OPERATION IRAQI FREEDOM (OIF) VETERANS
1. Do patients who are coming only for compensation and pension (C&P) examinations, but are not receiving any medical care within the Veterans Health Administration (VHA), need to have the screen completed?
No. Patients who present solely for compensation and pension exams do not need to have the screen completed. These patients are not being seen in VHA for medical care, but are being seen only for a specified disability assessment at the request of Veterans Benefits Administration (VBA).
2. Do active duty military personnel who served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) need to have the screen completed?
No. The screen is not mandated for active duty military personnel. Screening is optional. Follow-up of positive screens for this population may require referral back to their usual source of care in the military health system, depending upon the authorization received for VHA care.
3. Is screening to be done only in Primary Care or only in the “Nexus clinics?”
No. Screening is required for all patients receiving medical care within VHA, not just primary care or the Nexus clinics. Patients seen in Dental, Emergency Room, Urgent Care, or any other specialty clinic, or receiving inpatient care are to have the screen performed and the reminder completed.
4. Can patients with positive screens be referred to local non-VA practitioners or clinics for further evaluation?
All evaluations for positive screens are to be done by designated specialists who have completed training in the evaluation protocol. Most commonly, these are VHA Level II or Level III teams, or Spinal Cord Injury (SCI) teams. They have the multidisciplinary skills to complete the thorough evaluation required, and have been trained in the evaluation protocol. For medical centers that are not designated as a Level II Polytrauma Network Sites, or Level III Polytrauma Support Clinic Team, it is possible to determine an alternate plan and team that meets the intent of this Directive. This may include non-VA practitioners, or other VA staff specialists, such as neurologists, who have received, or will receive, training in the use of the evaluation protocol. Polytrauma Point of Contact or Level IV facilities wishing to complete the Traumatic Brain Injury (TBI) Second Level Evaluation locally must ensure that their alternate plan and team composition meets the intent of this Directive. Requests for alternate plans and teams need to be directed to the National Director for Physical Medicine and Rehabilitation through the Veterans Integrated Service Network (VISN) Chief Medical Officer (CMO). Data is collected systematically on the results of the evaluations as well as the screens. NOTE: This allows VHA
VHA DIRECTIVE 2019-012
March 8, 2010
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to understand the breadth of TBI related issues in OEF and OIF Veterans, and allows VHA to continuously improve its services.
5. Are only physicians and other practitioners with independent privileges allowed to complete the screens and submit referrals?
No. Other clinical staff members are allowed to perform the screens and complete the reminder. However, this staff needs to have completed the Veterans Health Initiative (VHI) TBI module. They need to understand the basics of TBI and what the evaluation protocol involves, so that they can respond to Veterans' questions knowledgeably and accurately. NOTE: Medical Centers can allow such clinical staff members to submit referral consults through approved standing orders approved by the medical staff.
6. If I see a non-OEF or OIF Veteran in my clinic who may have had a TBI, can this Veteran also receive a comprehensive evaluation?
Yes. Signs and symptoms of TBI are similar whether the injury is sustained in combat or non-combat situations. If you think a non-OEF or OIF Veteran has sustained a TBI, you should send a consult requesting evaluation and treatment to the same rehabilitation team that completes the comprehensive evaluation for OEF and OIF Veterans.

VA's Military Sexual Trauma [MST] Directive 2010-033

Department of Veterans Affairs VHA DIRECTIVE 2010-033
Veterans Health Administration
Washington, DC 20420 July 14, 2010
MILITARY SEXUAL TRAUMA (MST)
PROGRAMMING
1. PURPOSE: This Veterans Health Administration (VHA) Directive provides policy for
clinical care, monitoring, staff education, and informational outreach related to military sexual trauma (MST) counseling, care, and services.
2. BACKGROUND
a. Based on Title 38 United States Code (U.S.C.) 1720D, the Department of Veterans Affairs (VA) provides counseling, care, and services to Veterans and certain other Servicemembers who may not have Veteran status, but who experienced sexual trauma while serving on active duty or active duty for training. MST is defined as “psychological trauma, which in the judgment of a mental health professional employed by the Department, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was serving on active duty or active duty for training.” Sexual harassment is further defined as “repeated, unsolicited verbal or physical contact of a sexual nature, which is threatening in character.” MST-related care must be provided in a setting that is therapeutically appropriate, taking into account the circumstances that resulted in the need for such counseling. Public Law 103-452 removed limits on the duration of this care and specified that it must be available to both male and female survivors of MST. Public Law 108-422 made VA’s authorization to provide this care permanent.
b. VA has determined that because VA provides sexual trauma counseling and care pursuant to 38 U.S.C. Section 1720D only for sexual trauma-related disabilities that are incurred in service, there are no requirements for the condition to be adjudicated as service connected. Length of service or income eligibility requirements do not apply in order to receive this benefit. Veterans and eligible individuals who experienced MST while on active duty or active duty for training do not need to have filed a disability claim, be service connected, or provide evidence of the sexual trauma to receive MST-related care. Veterans and eligible individuals who report experiences of MST, but who are deemed ineligible for other VA health care benefits or enrollment, may be provided MST-related care only. This benefit extends to Reservists and members of the National Guard who were activated to full-time duty status in the Armed Forces. Veterans and eligible individuals who received an “other than honorable” discharge may be able to receive free MST-related care with the Veterans Benefits Administration (VBA) Regional Office approval. NOTE: For purposes of this Directive, “eligible individual” means someone without Veteran status who experienced sexual trauma as described in subparagraph 2a while on active duty or active duty for training. Because eligibility accrues as a result of events incurred in service and is not dependent on length of service some individuals may be eligible for MST-related care even if they do not have Veteran status.
c. All health care for treatment of mental and physical health conditions related to MST, including medications, is provided free of charge. Fee basis is available when it is clinically
THIS VHA DIRECTIVE EXPIRES JULY 31, 2015
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July 14, 2010
 
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inadvisable to provide counseling in a VA facility, when VA facilities are geographically inaccessible, or when VA facilities are unable to provide care in a timely manner. Referral to the local Readjustment Counseling Service (Vet Center) may also be an appropriate option. NOTE: Policies specific to the availability of MST-related care in Community-based Outpatient Clinics (CBOCs) are specified in VHA Handbook 1160.01.
d. Staff training and informational outreach are important components of MST-related programming. Mental health and other health care personnel must receive appropriate training on MST-related issues. VA engages in efforts to ensure that Veterans and potentially eligible individuals are informed about MST-related services available through VHA.
3. POLICY: It is VHA policy to provide Veterans and eligible individuals who report having experienced MST with free care for all physical and mental health conditions determined by their VA provider to be related to experiences of MST.
4. ACTION
a. Veterans Integrated Service Network (VISN) Director. The VISN Director is responsible for ensuring:
(1) Appointment of MST VISN-level Point of Contact (POC). Each VISN must have a designated MST VISN-level POC whose responsibilities are described in subparagraph 4b. The VISN MST POC needs to be a professional knowledgeable about mental health and informed about MST and treatment of its after-effects. This is a collateral position, but the MST POC needs to be given adequate protected time to fulfill the responsibilities of the role.
(2) Access to Specialized Residential or Inpatient Care. Veterans and eligible individuals must have access to residential or inpatient programs able to provide specialized MST-related mental health care, when clinically needed, for conditions resulting from MST. VISNs or VA medical centers that do not have these programs need to develop Memoranda of Understanding with VISNs that do have these services. NOTE: At a national level there is a need to consider developing a number of these programs as national resources and to arrange processes for referral, discharge, and follow-up.
b. VISN-level MST POC. The VISN-level MST POC is responsible for:
(1) Monitoring and helping to ensure national and VISN-level policies related to MST are implemented at individual facilities and associated CBOCs within the VISN;
(2) Providing support, assistance, and opportunities for communication and networking to MST Coordinators within the VISN; and
(3) Communicating with national, VISN, and facility-level leadership and other stakeholders.
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c. Facility Director. The Facility Director is responsible for ensuring:
(1) Appointment of an MST Coordinator. Every facility must have a designated MST Coordinator whose responsibilities are described in subparagraph 4d. The facility MST Coordinator needs to be a professional who is knowledgeable about trauma and mental health and who possesses expertise in issues specific to MST. Given that part of the role of the MST Coordinator is to provide information and assistance to Veterans and eligible individuals in accessing MST-related care at the facility and associated CBOCs, the MST Coordinator must be sensitive to issues arising in the clinical care of MST survivors, in order to handle these contacts appropriately. Although some facilities have established the MST Coordinator as a full-time position, it is permissible for the role to be assigned as a collateral duty. If this is the case, care must be taken to ensure that the MST Coordinator is given adequate protected time to fulfill the responsibilities of the role. Facility size and complexity, number of associated CBOCs, the size of the facility’s catchment area, and the size of the local MST population are to be considered in making this assessment. NOTE: Although the MST Coordinator may engage in the provision of clinical care to MST survivors as part of the MST Coordinator’s primary position, the MST Coordinator role is defined by screening and treatment program development, monitoring, staff education and training, informational outreach to Veterans and potentially eligible individuals, and other administrative responsibilities.
(2) Universal Screening. All Veterans and potentially eligible individuals seen in VHA facilities and associated CBOCs must be screened for experiences of MST. This must be done using the MST Clinical Reminder in the Computerized Patient Record System (CPRS), (see subpar. 4c(5)). Screening is to be conducted in appropriate clinical settings by providers with an appropriate level of clinical training; screenings are not to be conducted by clerks or health technicians.
(3) Availability of MST-related Care. Facilities and associated CBOCs must have appropriate physical and mental health care available for conditions related to MST. NOTE: Policies specific to the availability of MST-related care in CBOCs are specified in VHA Handbook 1160.01. Care must be delivered by staff with appropriate qualifications and training. Facilities must ensure that there is a sufficient number of clinicians trained in the provision of specialized mental health care related to MST to adequately meet the demand for care. Scheduling priority for outpatient sexual trauma counseling, care, and services is consistent with VHA performance standards for scheduling clinics. NOTE: When clinically indicated, facilities are strongly encouraged to accommodate the requests of Veterans and eligible individuals for a provider of a particular sex for their care for conditions related to MST.
(4) Co-payments. Veterans and eligible individuals are provided free care, with no inpatient, outpatient, or pharmacy co-payments, for mental and physical health conditions resulting from their experiences of MST. The provider of services makes the determination of whether the visit involved care related to a Veteran’s experiences of MST and must indicate this by checking the MST checkbox on the encounter form for the visit. Neither individuals nor health insurance plans are billed co-payments for MST-related inpatient, outpatient, or pharmaceutical treatment; however, applicable co-payments may be charged for services not related to MST. Facilities and associated CBOCs must have mechanisms in place to ensure that
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Veterans and potentially eligible individuals who may have conditions related to MST that require care, but who are not eligible for other VHA care, are able to be evaluated by a clinician to determine the applicability of the free care benefit.
(5) Monitoring of Screening, Referral, and Treatment. To ensure that national data on MST-related screening, referral, and treatment is accurate, the national MST software application must be installed and function properly at every facility and associated CBOCs. The national MST software application activates both the MST Clinical Reminder and, when applicable, the MST-related care encounter form checkbox in CPRS. The MST Clinical Reminder must be activated for all Veterans and potentially eligible individuals. Veterans and eligible individuals who screen positive for MST must have the MST-related care checkbox activated on their encounter forms and all MST-related care must be indicated by checking this box on the encounter form for the visit. Purpose of visit code 55, of the fee package, is recommended to indicate fee basis MST-related care. Because MST is an experience and not a diagnosis and because patients who report MST are provided free care for both physical and mental health conditions related to MST, care is often provided through a variety of clinics identified by a range of clinic stop codes. NOTE: Although some facilities have historically used clinic stop code 524 (Active Duty Sexual Trauma) as an indicator for MST-related care, this is not recommended as it cannot capture the full range of services for which patients are eligible.
(6) Education. Staff must receive education and training about MST-related issues appropriate to their role with Veterans and potentially eligible individuals. Providers of clinical services must be aware of the requirement to screen for MST and know how to screen sensitively, when appropriate to their role. They must also be aware of referral processes for treatment and recognize how a history of MST may affect their provision of care.
(7) Informational Outreach to Veterans. Information regarding VA’s services related to MST must be made available through appropriate public information services and must be visibly posted or displayed in appropriate places within the facility.
d. Facility MST Coordinator. The facility MST Coordinator is responsible for:
(1) Monitoring and helping to ensure national and VISN-level policies related to MST screening and treatment to ensure they are implemented at the facility and associated CBOCs. For example, MST has unique eligibility guidelines and monitoring requirements that MST Coordinators must help ensure are implemented. The MST Coordinator establishes and monitors mechanisms to ensure that all Veterans and potentially eligible individuals receiving VHA health care are screened for experiences of MST using the clinical reminder in CPRS, that those who screen positive have expedient access to a continuum of appropriate MST-related care, and that this care is provided free of charge. The MST Coordinator monitors local MST-related programming and, as needed, makes efforts to expand the program’s scope. MST survivors often have complex clinical needs and may be high utilizers of care; depending upon local needs and resources, programming may involve development of a specialized MST treatment team to ensure adequate coordination of care.
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(2) Monitoring and helping to ensure that national and VISN-level policies about staff education related to MST are implemented at the facility and associated CBOCs. The MST Coordinator directly provides or establishes and monitors mechanisms to ensure that staff at the facility and associated CBOCs receive legally-mandated education and training related to MST. Given VA policy of universal MST screening and the tendency for MST survivors to present with multiple mental and physical health comorbidities, education must occur in clinics throughout the facility and associated CBOCs. Depending upon a staff member’s role and level of contact with MST survivors, training needs to cover such topics as: sensitivity and confidentiality; treatment options; importance of, and rationale for, screening; potential impact of an MST history on provision of care; and background information on MST (e.g., prevalence of MST, impact of sexual trauma, etc.).
(3) Monitoring and helping to ensure that national and VISN-level policies about informational outreach related to MST are implemented at the facility and associated CBOCs. The MST Coordinator directly engages in and establishes and monitors mechanisms to provide informational outreach to Veterans and potentially eligible individuals and facilitates their engagement in care. The MST Coordinator ensures that Veterans and potentially eligible individuals are aware of the MST Coordinator role and contact information; and are familiar with local services available.
(4) Serving as a point of contact, source of information, and problem solver for MST-related issues at the facility and associated CBOCs.
(a) The MST Coordinator establishes formal mechanisms for communication and problem-solving related to MST issues at the facility and associated CBOCs, with a particular emphasis on establishing relationships with the facility Business Office (or other offices dealing with enrollment, eligibility, and billing issues); Information Resource Management Service; Women Veterans Health Program Manager; clinical directors in Mental Health, Primary Care, and other relevant clinical areas; and facility leadership among others.
(b) MST Coordinators serve as POC for Veterans and other individuals with questions about MST-related services at the facility and associated CBOCs. Accordingly, the MST Coordinator ensures that staff at various points of entry into the system (e.g., telephone operators, information desk staff, Mental Health clerks, Business Office staff) know the MST Coordinator’s role and contact information.
(c) MST Coordinators address systems issues that may create barriers to Veterans and eligible individuals entering care and act as an advocate for Veterans and eligible individuals in their interactions with relevant VHA clinics and offices. For example, when fee basis care is warranted, the facility credentialing and privileging system must be notified prior to the initial visit with the fee basis provider; this notification alerts the credentialing and privileging system to obtain information needed to update the provider’s file and authorize prescription of medications.
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(d) MST Coordinators help ensure that systems are in place to prevent Veterans and eligible individuals from encountering difficulties in obtaining reimbursement, filling prescribed medications, or receiving appropriate care.
(5) Communicating with national, VISN, facility-level leadership, and other stakeholders. The MST Coordinator communicates regularly with the VISN-level MST POC and other MST Coordinators in the VISN, as well as local mental health and national MST leadership in order to remain knowledgeable about policies and trends related to MST. In addition, the MST Coordinator responds to requests for information about local MST programming from VA Central Office’s Office of Mental Health Services.
5. REFERENCES
a. Public Law 103-452, Veterans Health Care Extension Act, dated November 2, 1994.
b. Public Law 108-422, Veterans Health Program Improvement Act of 2004, dated November 30, 2004.
c. Title 38 U.SC. 1720D, Counseling and treatment for sexual trauma.
d. Office of General Counsel document, Military Sexual Trauma, dated June, 2006.
e. VHA Handbook 1160.01.
6. FOLLOW-UP RESPONSIBILITY: Office of Mental Health Services (116) is responsible for the contents of this Directive. Questions may be referred the Director, Family Services, Women’s Mental Health, and Military Sexual Trauma, at: 202-340-4192.
7. RECISSIONS: VHA Directive 2005-015 is rescinded. This VHA Directive expires
July 31, 2015.
Robert A. Petzel, M.D.
Under Secretary for Health
DISTRIBUTION:
E-mailed to the VHA Publications Distribution List 7/15/2010