D.17- VHA DIRECTIVE 1003.04 VHA PATIENT ADVOCACY NOV 2023.pdf

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Department of Veterans Affairs VHA DIRECTIVE 1003.04 Veterans Health Administration Transmittal Sheet Washington, DC 20420 November 9, 2023

VHA PATIENT ADVOCACY

1. SUMMARY OF MAJOR CHANGES: Major changes include:

a. Adding and updating roles and responsibilities for the Executive Director, Office of Patient Advocacy; Veterans Integrated Services Network (VISN) Director; VISN Patient Advocate Coordinator; VISN Patient Advocate Tracking System (PATS) Coordinator;

VISN Organizational Specialist; Department of Veterans Affairs (VA) medical facility Director; VA medical facility Patient Advocate Supervisor; VA medical facility Patient Advocate; VA medical facility Organizational Specialist; VA medical facility PATS Coordinator; VA medical facility Service Chief; and VA medical facility Service Level Advocate (SLA) (see paragraph 2).

b. Adding the Comprehensive Addiction and Recovery Act of 2016 requirements for quarterly VA medical facility community town hall meetings and VISN Director attendance; and inspection of controlled substances (see paragraph 2).

c. Adding complaint management procedures for Patient Advocates, Organizational Specialists and SLA PATS user roles (see paragraph 3).

d. Adding PATS documentation quality standards and updating PATS data reporting elements (see paragraph 4).

e. Adding procedures for the management of complaints that were previously resolved (see paragraph 5).

f. Updating training requirements for Patient Advocates and adding training requirements for PATS users (see paragraph 7).

g. Adding a sample complaint closure letter due to inability to make contact (see Appendix A).

2. RELATED ISSUES: VHA Directive 1041, Appeal of Veterans Health Administration Clinical Decisions, dated September 28, 2020; VHA Directive 1112, Correspondence Requiring No Response (No Reply), dated September 30, 2020; VHA Directive 1199(2), Reporting Cases of Abuse and Neglect, dated November 28, 2017; VHA Directive 5019.02(1), Harassment, Sexual Assaults and Other Defined Public Safety Incidents in Veterans Health Administration, dated September 12, 2022.

3. POLICY OWNER: The Office of Patient Advocacy (10PADV) is responsible for the content of this directive. Questions may be referred to VHA10PADVAction@va.gov.

4. RESCISSIONS: VHA Directive 1003.04, VHA Patient Advocacy, dated February 7, 2008, is rescinded.

Attachment D.17 RFP 36C24224R0049 mailto:VHA10PADVAction@va.gov

November 9, 2023 VHA DIRECTIVE 1003.04

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5. RECERTIFICATION: This Veterans Health Administration (VHA) directive is scheduled for recertification on or before the last working day of November 2028. This VHA directive will continue to serve as national VHA policy until it is recertified or rescinded.

6. IMPLEMENTATION SCHEDULE: This directive is effective upon publication.

BY DIRECTION OF THE OFFICE OF

THE UNDER SECRETARY FOR HEALTH:

/s/ Shereef Elnahal, M.D., MBA Under Secretary for Health

NOTE: All references herein to VA and VHA documents incorporate by reference subsequent VA and VHA documents on the same or similar subject matter.

DISTRIBUTION: Emailed to the VHA Publications Distribution List on November 13, 2023.

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CONTENTS

VHA PATIENT ADVOCACY

1. POLICY

2. RESPONSIBILITIES

3. COMPLAINT MANAGEMENT PROCEDURES

4. PATIENT ADVOCATE TRACKING SYSTEM DATA ENTRY, INFORMATION AND

ANALYSIS

5. MANAGING COMPLAINTS PREVIOUSLY RESOLVED

6. EXTERNAL ADVOCACY GROUPS AND PATIENT REPRESENTATIVES

7. TRAINING

8. RECORDS MANAGEMENT

9. BACKGROUND

10. DEFINITIONS

11. REFERENCES

APPENDIX A

SAMPLE COMPLAINT CLOSURE LETTER DUE TO INABILITY TO MAKE CONTACT

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VHA PATIENT ADVOCACY

1. POLICY

It is Veterans Health Administration (VHA) policy that patient advocacy, as a fundamental value in VHA’s culture, considers the needs, preferences, priorities and values of Veterans in a proactive and convenient manner. AUTHORITY: 38 U.S.C. §§ 7301(b), 7309A.

2. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for:

(1) Ensuring overall VHA compliance with this directive.

(2) Supporting the Office of Patient Advocacy (OPA) with implementation and oversight of this directive.

b. Assistant Under Secretary for Health for Operations. The Assistant Under Secretary for Health for Operations is responsible for:

(1) Communicating the contents of this directive to each of the Veterans Integrated Services Networks (VISNs).

(2) Assisting VISN Directors to resolve implementation and compliance challenges in all Department of Veterans Affairs (VA) medical facilities within that VISN.

(3) Providing oversight of VISNs to ensure compliance with this directive and its effectiveness.

c. Executive Director, Office of Patient Advocacy. The Executive Director, OPA is responsible for:

(1) Providing policy, guidance, technical support, training and education for the implementation and sustainment of VHA patient advocacy.

(2) Providing guidance to VISN and VA medical facility Directors annually through established VISN meetings to ensure understanding and fulfillment of required patient advocacy program management duties; obtaining feedback from VISN and VA medical facility Directors related to promising patient advocacy practices and challenges, Veteran feedback and system-wide opportunities for improvement in support of improving VHA patient advocacy.

(3) Implementing a standardized complaint management process; see paragraph 3.

(4) Providing oversight and maintenance of the Patient Advocate Tracking System (PATS), VHA’s complaint management system of record, and any subsequent versions of the tool. NOTE: As required by the Privacy Act of 1974, PATS has an established

System of Record Notice entitled Patient Advocate Tracking System Replacement

(PATS-R)-VA (100VA10H).

(5) Reporting PATS data, at least quarterly, to the Under Secretary for Health and Assistant Under Secretary for Health for Operations; identifying potential opportunities for improvement.

(6) Implementing a quality improvement process for monitoring PATS documentation to validate data accuracy, ensure comprehensive complaint resolution and ensure patient contact expectations are met.

(7) Providing PATS data connections, as appropriate, with standard VHA data warehouse and storage repositories such as VHA Service Support Center, Survey of Healthcare Experiences of Patients, Performance Measurement Report, and Strategic Analytics for Improvement and Learning (SAIL).

(8) Collaborating with VHA national program offices to ensure Veteran complaints concerning health care are captured and documented in PATS.

(9) Consulting with VISN patient advocacy staff, including but not limited to debriefing VISN Patient Advocate Coordinators (VPACs) after managing escalated complaints, reviewing difficult or challenging complaints, discussing complaint challenges, reflecting on the outcomes and identifying lessons learned and improvement opportunities.

d. Veterans Integrated Services Network Director. The VISN Director is responsible for:

(1) Ensuring that all VA medical facilities within the VISN comply with this directive and informing leadership when barriers to compliance are identified.

(2) Ensuring that an effective, efficient VISN patient advocacy program is implemented to include the following:

(a) Identifying a VPAC who is organizationally aligned under and directly reports to a member of the VISN Executive Leadership Team (ELT). NOTE: For the purposes of this directive, the VISN ELT is the VISN Director, VISN Deputy Director, VISN Chief Medical Officer, VISN Chief Nursing/Quality Management Officer and VISN Associate Director.

(b) Staffing the VISN patient advocacy program appropriately to meet evolving workload challenges and nationally established workload-based outcomes. For additional information on workload-based outcomes, see https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful%20Information/For ms/AllItems.aspx?OR=Teams%2DHL&CT=1678120935134&id=%2Fsites%2FVACOPa tientAdvocacy%2FHelpful%20Information%2FStaffing%20Guidance&viewid=5c5ec074 %2Da077%2D4579%2Da7e2%2D60588f250df6. NOTE: This is an internal VA website that is not available to the public.

(c) Ensuring that PATS is used as the system of record for all Veteran complaints

Attachment D.17 RFP 36C24224R0049 https://urldefense.com/v3/__https:/dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful*20Information/Forms/AllItems.aspx?OR=Teams*2DHL&CT=1678120935134&id=*2Fsites*2FVACOPatientAdvocacy*2FHelpful*20Information*2FStaffing*20Guidance&viewid=5c5ec074*2Da077*2D4579*2Da7e2*2D60588f250df6__;JSUlJSUlJSUlJSUl!!May37g!JbeQOcBlV9kt8vp4iOyWhXR3stTdjWO8ghYE_7POokFEtHt_SJRKFiweQcowKR8YeMk7HhFQ20-cuLMzMQUzfIb9CKKU$ https://urldefense.com/v3/__https:/dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful*20Information/Forms/AllItems.aspx?OR=Teams*2DHL&CT=1678120935134&id=*2Fsites*2FVACOPatientAdvocacy*2FHelpful*20Information*2FStaffing*20Guidance&viewid=5c5ec074*2Da077*2D4579*2Da7e2*2D60588f250df6__;JSUlJSUlJSUlJSUl!!May37g!JbeQOcBlV9kt8vp4iOyWhXR3stTdjWO8ghYE_7POokFEtHt_SJRKFiweQcowKR8YeMk7HhFQ20-cuLMzMQUzfIb9CKKU$ https://urldefense.com/v3/__https:/dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful*20Information/Forms/AllItems.aspx?OR=Teams*2DHL&CT=1678120935134&id=*2Fsites*2FVACOPatientAdvocacy*2FHelpful*20Information*2FStaffing*20Guidance&viewid=5c5ec074*2Da077*2D4579*2Da7e2*2D60588f250df6__;JSUlJSUlJSUlJSUl!!May37g!JbeQOcBlV9kt8vp4iOyWhXR3stTdjWO8ghYE_7POokFEtHt_SJRKFiweQcowKR8YeMk7HhFQ20-cuLMzMQUzfIb9CKKU$ https://urldefense.com/v3/__https:/dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful*20Information/Forms/AllItems.aspx?OR=Teams*2DHL&CT=1678120935134&id=*2Fsites*2FVACOPatientAdvocacy*2FHelpful*20Information*2FStaffing*20Guidance&viewid=5c5ec074*2Da077*2D4579*2Da7e2*2D60588f250df6__;JSUlJSUlJSUlJSUl!!May37g!JbeQOcBlV9kt8vp4iOyWhXR3stTdjWO8ghYE_7POokFEtHt_SJRKFiweQcowKR8YeMk7HhFQ20-cuLMzMQUzfIb9CKKU$ and PATS data is incorporated into VISN-level governance, reporting and improvement efforts.

(3) Ensuring that Veteran complaints at the VISN-level are managed by VISN patient advocacy program staff in accordance with the procedures in this directive and within OPA-designated timeframes (see paragraph 3).

(4) Ensuring that VISN PATS data is tracked, trended, analyzed and disseminated at least quarterly across the VISN to leadership for decision making, strategic planning processes and quality improvement initiatives.

(5) Ensuring that VISN staff follow this directive when engaging with external stakeholders who seek to represent patients in VA medical facilities, including Veterans Service Organizations (VSOs) and representatives of State protection and advocacy systems. NOTE: For further information on external advocacy, see paragraph 6.

(6) Ensuring the fulfillment of the requirements established by the Comprehensive Addiction and Recovery Act (CARA), P.L. 114-198 § 921 with respect to Veteran community meetings. NOTE: Pursuant to CARA, each VA medical facility should host a community meeting (town hall) open to the public on improving health care provided no less frequently than once every 90 days. In addition, no less frequently than once a year, each Community-based Outpatient Clinic (CBOC) should host a community meeting (town hall) open to the public on improving health care provided. Each community meeting (town hall) hosted by a VA medical facility or CBOC must be attended by the VISN Director or a designee that works within the Office of the VISN Director. Each VISN Director must personally attend no less than one community meeting (town hall) hosted by each VA medical facility each year.

e. Veterans Integrated Services Network Patient Advocate Coordinator. NOTE:

The VPAC is a designated role with full authority to represent and act on behalf of the VISN on all matters related to VHA patient advocacy. This includes serving as a liaison between OPA and VA medical facility Patient Advocate Offices. The VPAC is responsible for:

(1) Providing VISN-level oversight and management of Veteran complaints in PATS and ensuring timely resolution based on OPA-designated timeframes and quality documentation standards that supports complaint closure (see paragraph 4 for additional information). NOTE: Designated timeframes for resolving specific types of complaints are established by OPA and can be found on the PATS Resources page (see PATS Issue Codes and Definitions) of OPA SharePoint at https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/PATS%20Resources/Form s/AllItems.aspx?FolderCTID=0x012001&viewid=aa93b09a%2D9cdd%2D40bc%2Dab03 %2D661913bf5de5. This is an internal VA website that is not available to the public.

(2) Providing direct support and guidance to VISN Office Patient Advocates on documenting and coordinating resolution for Veteran complaints that could not be resolved at the VA medical facility level. NOTE: In the absence of VISN Office Patient Advocates, VPACs serve in this capacity.

Attachment D.17 RFP 36C24224R0049 https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/PATS%20Resources/Forms/AllItems.aspx?FolderCTID=0x012001&viewid=aa93b09a%2D9cdd%2D40bc%2Dab03%2D661913bf5de5 https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/PATS%20Resources/Forms/AllItems.aspx?FolderCTID=0x012001&viewid=aa93b09a%2D9cdd%2D40bc%2Dab03%2D661913bf5de5 https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/PATS%20Resources/Forms/AllItems.aspx?FolderCTID=0x012001&viewid=aa93b09a%2D9cdd%2D40bc%2Dab03%2D661913bf5de5

(3) Implementing this directive, in addition to OPA guidance, initiatives and patient advocacy standardization efforts, across the VISN.

(4) Collecting, analyzing, and trending VISN PATS data for use in quality and process improvement, strategic planning, employee engagement and risk management activities.

(5) Monitoring VISN PATS user documentation, at least monthly, to validate complaints are clearly captured, acted upon, well documented and correctly coded.

(6) Identifying PATS trends, at least quarterly, to provide recommendations for focused system-level improvement efforts to applicable committee meetings and workgroups.

(7) Training, assisting, mentoring, coaching and guiding VA medical facility Patient Advocate Supervisors, as needed.

(8) Serving on VISN-level and national committees that support or have an impact on VHA patient advocacy.

(9) Consulting with VA medical facility Patient Advocate Offices, to include but not limited to debriefing Patient Advocate Supervisors after managing very difficult or challenging complaints to review the complaint, discuss challenges, reflect on the outcome and identify lessons learned. NOTE: Should a conflict of interest arise within a VA medical facility with a health care complaint, the VPAC is empowered to act with full support of the VISN ELT to work with the VA medical facility ELT and Patient Advocate Office to address the complaint.

f. Veterans Integrated Service Network Patient Advocate Tracking System Coordinator. NOTE: The VISN PATS Coordinator is a collateral role that conducts PATS training and assists PATS users in troubleshooting user issues and errors. This includes serving as a liaison between OPA and VA medical facility Patient Advocate Offices regarding PATS. The VISN PATS Coordinator is responsible for:

(1) Assisting VA medical facility Patient Advocate Offices in the licensing of new PATS users and provisioning PATS users into the appropriate role in the absence of a VA medical facility PATS Coordinator.

(2) Validating and submitting requests for new PATS VISN and VA medical facility service lines to OPA for review and action.

(3) Providing PATS training to system users.

(4) Assisting VA medical facility PATS Coordinators in troubleshooting issues.

(5) Reviewing requests received from the VA medical facility PATS Coordinator to add or remove VA medical facility service lines in PATS.

g. Veterans Integrated Service Network Organizational Specialist. The VISN Organizational Specialist (VOS) is responsible for:

(1) Coordinating and addressing complaints received from Veterans or actioned to the VISN in PATS within 2 business days, or if determined the complaint was not routed to the correct VISN, rejecting the PATS complaint and sending it back to the VISN or VA medical facility within 2 business days. See paragraph 3.a.(4)(a) for additional information.

(2) Resolving open PATS complaints based on designated timeframes (see paragraph 3) and entering quality documentation that supports complaint closure by the Patient Advocate (see paragraph 4).

(3) Assisting service lines or VA medical facilities in resolving issues after first attempts at resolution have not been successful.

(4) Ensuring ongoing communication with Veterans about their complaints, including pending actions and final resolution, until the complaint has been closed.

h. VA Medical Facility Director. The VA medical facility Director is responsible for:

(1) Ensuring that an effective, efficient patient advocacy program is implemented to include the following:

(a) Identifying a Patient Advocate Supervisor who is organizationally aligned under and directly reports to a member of the VA medical facility ELT. NOTE: For the purposes of this directive, the VA medical facility ELT is the VA medical facility Director, VA medical facility Deputy Director, VA medical facility Associate Director(s), VA medical facility Chief of Staff, VA medical facility Associate Director for Patient Care Services and Assistant Director(s).

(b) Staffing the PA Office appropriately to meet evolving workload challenges and nationally established workload-based outcomes measures.

(c) Ensuring that PATS is used as the system of record for all Veteran complaints and PATS data is incorporated into VA medical facility-level governance, reporting and improvement efforts.

(d) Ensuring that each VA medical facility Service Chief has a designated Service Level Advocate(s) (SLA) who actively works within PATS to document and address complaints within the designated timeframes at the point of service.

(e) Ensuring that SLA contact information is easily accessible for Veterans and the Patient Advocate Office.

(2) Ensuring that VA medical facility PATS data is tracked, trended, analyzed and disseminated across the VA medical facility to leadership for decision making, strategic planning processes and quality improvement initiatives.

(3) Ensuring that the Patient Advocate Office is included in organizational leadership meetings and other key VA medical facility committees where Veteran feedback data is essential to mission success. This includes but is not limited to Morning Report, Disruptive Behavior Committee, Customer Service Committee, Systems Redesign/Process Improvement Committee and the Strategic Planning Committee.

(4) Ensuring that Patient Rights are posted in every VA medical facility and CBOC near entrances and in high-traffic areas where appropriate.

(5) Ensuring that Patient Advocate pictures and information are posted on the VA medical facility website and in every VA medical facility and CBOC, where appropriate.

(6) Fulfilling the requirements established by CARA, P.L. 114-198, § 921 with respect to Veteran community meetings. NOTE: Per CARA, each VA medical facility should host a community meeting (town hall) open to the public on improving health care provided no less frequently than once every 90 days. In addition, not less frequently than once a year, each CBOC should host a community meeting (town hall) open to the public on improving health care provided. Notifications should be sent to the offices of Members of Congress who represent the area in which the VA medical facility is located by no later than 10 business days before such community meeting (town hall) occurs.

(7) Assisting the Controlled Substance Coordinator in ensuring complaints related to possible diversion activities at the VA medical facility are included in monthly reporting required by VHA Directive 1108.02(2), Inspection of Controlled Substances, dated November 28, 2016.

i. VA Medical Facility Service Chief. VA medical facility Service Chiefs are responsible for:

(1) Designating service line staff to serve in the collateral role of SLAs working actively in PATS to address complaints.

(2) Providing oversight of complaints assigned to the service line in PATS and ensuring timely resolution based on designated timeframes and quality documentation that supports complaint closure.

(3) Ensuring timely entry and resolution of complaints by SLAs. NOTE: Initial documentation of a complaint should occur in real-time or the same day the complaint is received.

(4) Ensuring PATS data is collected, analyzed and trended for use in service-level quality improvement, strategic planning, employee engagement, process improvement and risk management activities.

j. VA Medical Facility Patient Advocate Supervisor. NOTE: The VA medical facility Patient Advocate Supervisor can be a stand-alone position or a responsibility of another role (e.g., Patient Advocacy Chief, Patient Advocacy Program Manager, Quality

Management Officer). The VA medical facility Patient Advocate Supervisor is responsible for:

(1) Providing oversight for Patient Advocates and patient advocacy program activities.

(2) Providing direct support and guidance to Lead Patient Advocates, if applicable.

NOTE: This is applicable to VA medical facilities who have included this non-supervisory position(s) in their Patient Advocate Office structure to provide support to the Patient Advocate Supervisor.

(3) Providing Patient Advocate Just in Time (JIT) training, guidance and instruction to understand their roles and responsibilities, including responsibility for the overall coordination of patient advocacy program activities. See paragraph 7 for additional information on training.

(4) Providing JIT training and support to VA medical facility employees in understanding:

(a) The responsibility each employee has, to advocate on behalf of Veterans.

(b) The expectation of quality documentation within PATS.

(c) Complaint processes and options that are available to assist Veterans.

(5) Implementing OPA initiatives and patient advocacy standardization efforts across the VA medical facility.

(6) Ensuring that Patient Advocates enter and close patient complaints in PATS based on designated timeframes and provide documentation that addresses the complaint. NOTE: Initial documentation of a complaint by Patient Advocate should occur in real time or the same day the complaint is received and be closed by the designated timeframe.

(7) Collecting, analyzing and identifying trends in VA medical facility PATS data for use in quality improvement, strategic planning, employee engagement, process improvement and risk management activities.

(8) Monitoring VA medical facility PATS user documentation, at least monthly, to validate complaints are clearly captured, acted upon, well documented and correctly coded.

(9) Communicating PATS trends and quality improvement opportunities, at least quarterly, to provide recommendations for focused system-level improvement efforts to the VA medical facility ELT and applicable committees and workgroups. NOTE: This communication may be sent directly to the ELT or through the VA medical facility governance structure.

(10) In collaboration with VA Police and the Mental Health Service, establishing protocols to support physical and psychological safety of Patient Advocates.

(11) Debriefing with Patient Advocacy Office staff after managing very difficult or challenging complaints to review the complaint, discuss challenges, reflect on the outcome and identify lessons learned and possible opportunities for improvement.

NOTE: Should a conflict of interest arise with a complaint, the Patient Advocate Supervisor may engage the VPAC for assistance in addressing the complaint.

(12) Ensuring compliance with the requirements for the management of clinical appeals specified in VHA Directive 1041, Appeal of Veteran Health Administration Clinical Decisions, dated September 28, 2020.

k. VA Medical Facility Patient Advocate Tracking System Coordinator. NOTE:

The VA medical facility PATS Coordinator is a collateral role that conducts PATS training and assists PATS users in troubleshooting user issues and errors. This includes serving as a liaison between the VA medical facility and VISN PATS Coordinator. The coordinator is responsible for:

(1) Adding, modifying and removing PATS users accounts.

(2) Submitting requests to add or remove VA medical facility service lines in PATS to the VISN PATS Coordinator for review and action.

(3) Providing PATS training to VA medical facility staff.

(4) Assisting VA medical facility PATS users with troubleshooting issues.

l. VA Medical Facility Patient Advocate. The VA medical facility PA is responsible for:

(1) Documenting Veteran complaints in PATS and coordinating resolution in partnership with SLAs. See paragraph 3.a. This includes ensuring the documentation entered is complete and actionable. NOTE: Patient Advocates are not permitted to have documentation capabilities within the electronic health record.

(2) Coordinating resolution for complaints that cannot be resolved at the point of service or require assistance from multiple service lines.

(3) Notifying the VA medical facility Patient Advocate Supervisor when very difficult or challenging complaints have been identified and more support is needed.

(4) Providing guidance and support to SLAs in their efforts to address complaints in PATS, within their service line, by the designated timeframe.

(5) Engaging with the VA medical facility Patient Advocate Supervisor or VPAC should a conflict of interest arise with a complaint for assistance in addressing that complaint.

(6) Collaborating with service line management in the creation, development and implementation of initiatives to improve issues identified through PATS data.

(7) Assisting the VA medical facility Patient Advocate Supervisor in providing JIT training to ensure VA medical facility employees understand the following:

(a) The responsibility each employee has, to advocate on behalf of Veterans.

(b) The expectation of quality documentation within PATS (see paragraph 4.a.).

(c) Complaint processes and options that are available to assist Veterans.

(8) Providing documentation to VA medical facility Privacy Officers (or Release of Information Office) in response to Veteran requests for copies of their complaint records. Patient Advocates are prohibited from providing complaint documentation directly to Veterans.

(9) Reporting and documenting special cases in PATS as described in paragraph 4.b.

(10) Complying with the responsibilities for clinical appeals specified in VHA Directive 1041.

m. VA Medical Facility Organizational Specialist. The VA medical facility Organizational Specialist (FOS) is responsible for:

(1) Coordinating and addressing complaints received from Veterans or assigned to the VA medical facility in PATS within 2 business days, or if it is determined the complaint was not routed to the correct VA medical facility, rejecting the PATS complaint and sending it back to the sender within 2 business days. See paragraph 3.b.

for additional information.

(2) Resolving open PATS complaints based on designated timeframes (see paragraph 3) and entering quality documentation that supports complaint closure by the Patient Advocate (see paragraph 4).

(3) Ensuring ongoing communication with Veterans about their complaints, including pending actions and final resolution, until the complaint has been closed.

n. VA Medical Facility Service Level Advocate. VA medical facility SLAs are responsible for:

(1) Coordinating and addressing complaints actioned to the service line in PATS within 2 business days, or if determined the complaint was not routed to the correct business line, rejecting the PATS complaint back to the VA medical facility Patient Advocate within 2 business days. See paragraph 3.c. for additional information.

(2) Entering and resolving open PATS complaints based on designated timeframes (see paragraph 3) and entering quality documentation that supports complaint closure by the Patient Advocate (see paragraph 4).

(3) Assisting service lines in resolving issues after first attempts at resolution have not been successful and identifying opportunities for improvement within their service line or adjacencies with other service lines.

(4) Communicating regularly with Veterans about their complaints, including pending actions and final resolution, until the complaint has been closed.

(5) Collecting, analyzing and identifying trends in service line PATS data for use in quality improvement, strategic planning, employee engagement, process improvement and risk management activities.

3. COMPLAINT MANAGEMENT PROCEDURES

These procedures apply specifically to the management of complaints. NOTE:

Clinical appeals must follow VHA Directive 1041. In addition, these procedures do not apply to compliments or recommendations, which generally do not require action except for the purpose of communicating gratitude or follow-up with questions for insights or better understanding related to an inquiry.

a. Patient Advocate in Receipt of Complaint from Veteran.

(1) A Veteran initiates a complaint in person or in writing.

(2) Upon receipt of the complaint, the Patient Advocate reviews PATS and other available resources to determine if the issue is currently being addressed or has been resolved. If the issue is currently being addressed or has been resolved, the Veteran must be notified.

(3) After confirming that the complaint addresses a new issue, the Patient Advocate documents the complaint in PATS on the day of receipt and includes any necessary documents provided by the Veteran as attachments.

(4) The Patient Advocate transmits the complaint on the day of receipt to the appropriate service line(s) for review. Once any necessary follow up actions are taken, the appropriate service line(s) communicates a resolution to the Veteran, and adds notes, activities, the final resolution and any applicable attachments within PATS.

(a) Complaint Action in PATS. New complaints received by the service line from the Patient Advocate must be reviewed by the SLA and assigned within 2 business days to the appropriate personnel to address the complaint. If the SLA determines that the complaint was not routed to the appropriate service line, the SLA must reject the PATS complaint within 2 business days and return it to the PA for appropriate action.

(b) Veterans Unable to be Reached. Three contact attempts must be made on different days and times of the day to reach a Veteran to address their complaint. With each attempt, a phone message must be left that includes a direct line phone number or extension for the Veteran to reach the appropriate VHA point of contact. Each attempt must be documented in PATS using a new patient contact activity. After the third unsuccessful attempt, the SLA must mail the Veteran a complaint closure notification letter. See Appendix A for a sample letter. The SLA must resolve the complaint in PATS by documenting that the Veteran was unable to be contacted using a resolution activity and by attaching the complaint closure notification letter.

(c) Complaints Open Past the Designated Timeframe. For those complaints unable to be appropriately resolved by the designated timeframe, a follow-up call must be made to the Veteran providing a status update, and the call must be documented in PATS as a patient contact activity. NOTE: OPA has designated timeframes for specific types of complaints. Additional information can be found on the PATS Resource page (see PATS Issue Codes and Definitions) of OPA SharePoint:

https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful%20Information/For ms/AllItems.aspx?OR=Teams%2DHL&CT=1678120935134&id=%2Fsites%2FVACOPa tientAdvocacy%2FHelpful%20Information%2FStaffing%20Guidance&viewid=5c5ec074 %2Da077%2D4579%2Da7e2%2D60588f250df6. This is an internal VA website that is not available to the public.

(5) Upon receiving the resolution activity response from the SLA, the Patient Advocate must review the documentation for completeness; ensuring that the resolution responds to the complaint, patient contact(s) are documented, and applicable attachments are included; assign the most accurate issue code and close the complaint in PATS.

b. Organizational Specialist in Receipt of Complaint from Veteran.

(1) A Veteran initiates a complaint in writing (e.g., VA medical facility Director, Congressional or White House letter), phone call, or through a PATS system integration.

(2) Upon receipt of the complaint, the Organizational Specialist (OS) (i.e., VOS or FOS) reviews PATS and other available resources to determine if the issue is currently being addressed or has been resolved. If the issue is being addressed or has been resolved, the Veteran must be notified.

(3) After confirming that the complaint addresses a new issue, the OS documents of the complaint in PATS on the day of receipt and includes any necessary documents provided by the Veteran as attachments. Complaints from PATS integrations must be reviewed and routed to the appropriate service line within 2 business days.

(4) The OS transmits the complaint on the same day to the appropriate service line(s) for review. The appropriate service line(s) will communicate a resolution to the Veteran, documenting notes, activities, final resolution, and any applicable attachments within PATS.

(a) Complaint Action in PATS. New complaints received by the service line from the

Attachment D.17 RFP 36C24224R0049 https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/PATS%20Resources/Forms/AllItems.aspx?viewpath=%2Fsites%2FVACOPatientAdvocacy%2FPATS%20Resources%2FForms%2FAllItems%2Easpx https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful%20Information/Forms/AllItems.aspx?OR=Teams%2DHL&CT=1678120935134&id=%2Fsites%2FVACOPatientAdvocacy%2FHelpful%20Information%2FStaffing%20Guidance&viewid=5c5ec074%2Da077%2D4579%2Da7e2%2D60588f250df6 https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful%20Information/Forms/AllItems.aspx?OR=Teams%2DHL&CT=1678120935134&id=%2Fsites%2FVACOPatientAdvocacy%2FHelpful%20Information%2FStaffing%20Guidance&viewid=5c5ec074%2Da077%2D4579%2Da7e2%2D60588f250df6 https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful%20Information/Forms/AllItems.aspx?OR=Teams%2DHL&CT=1678120935134&id=%2Fsites%2FVACOPatientAdvocacy%2FHelpful%20Information%2FStaffing%20Guidance&viewid=5c5ec074%2Da077%2D4579%2Da7e2%2D60588f250df6 https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful%20Information/Forms/AllItems.aspx?OR=Teams%2DHL&CT=1678120935134&id=%2Fsites%2FVACOPatientAdvocacy%2FHelpful%20Information%2FStaffing%20Guidance&viewid=5c5ec074%2Da077%2D4579%2Da7e2%2D60588f250df6

OS must be reviewed by the SLA and assigned within 2 business days to the appropriate personnel to address the complaint. If the SLA determines that the complaint was not routed to the appropriate service line, the SLA must reject the complaint within 2 business days and return it to the SLA for further action.

(b) Veterans Unable to be Reached. Three contact attempts must be made on different days and times of the day to reach a Veteran to address their complaint. With every attempt, a phone message must be left that includes a direct line phone number or extension for the Veteran to reach the appropriate VHA point of contact. Each attempt must be documented in PATS using a new patient contact activity. After the third unsuccessful attempt, the SLA must mail the Veteran a complaint closure notification letter. See Appendix A for additional information. The SLA must resolve the complaint in PATS by documenting that the Veteran was unable to be contacted using a resolution activity and by attaching the complaint closure notification letter.

(c) Complaints Open Past the Designated Timeframe. For complaints unable to be appropriately closed by the designated timeframe, a follow-up call must be made to the Veteran providing a status update, and the call must be documented in PATS as a patient contact activity. NOTE: OPA has approved designated timeframes for specific types of complaints. Additional information can be found on the OPA SharePoint:

https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful%20Information/For ms/AllItems.aspx?OR=Teams%2DHL&CT=1678120935134&id=%2Fsites%2FVACOPa tientAdvocacy%2FHelpful%20Information%2FStaffing%20Guidance&viewid=5c5ec074 %2Da077%2D4579%2Da7e2%2D60588f250df6. NOTE: This is an internal VA website that is not available to the public.

(5) Upon receiving the resolution activity response from the SLA, the OS must review the documentation for completeness, attach any final documents, accept the resolution and route the action to the Patient Advocate.

(6) Upon receiving the accepted resolution activity/response from the OS, the Patient Advocate will review the documentation for completeness; ensuring that the resolution responds to the complaint, patient contact(s) are documented, and applicable attachments are included; assign the most accurate issue code(s) and close the complaint in PATS.

c. Service Level Advocate in Receipt of Complaint from Veteran.

(1) A Veteran initiates a complaint in person or in writing.

(2) Upon receipt of the complaint, the SLA reviews PATS and other available resources to determine if the issue is currently being addressed or has been resolved. If the issue is currently being addressed or has been resolved, the Veteran must be notified.

(3) After confirming that the complaint addresses a new issue, the SLA documents the complaint in PATS on the same day and includes any necessary documents provided by the Veteran as attachments.

Attachment D.17 RFP 36C24224R0049 https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful%20Information/Forms/AllItems.aspx?OR=Teams%2DHL&CT=1678120935134&id=%2Fsites%2FVACOPatientAdvocacy%2FHelpful%20Information%2FStaffing%20Guidance&viewid=5c5ec074%2Da077%2D4579%2Da7e2%2D60588f250df6 https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful%20Information/Forms/AllItems.aspx?OR=Teams%2DHL&CT=1678120935134&id=%2Fsites%2FVACOPatientAdvocacy%2FHelpful%20Information%2FStaffing%20Guidance&viewid=5c5ec074%2Da077%2D4579%2Da7e2%2D60588f250df6 https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful%20Information/Forms/AllItems.aspx?OR=Teams%2DHL&CT=1678120935134&id=%2Fsites%2FVACOPatientAdvocacy%2FHelpful%20Information%2FStaffing%20Guidance&viewid=5c5ec074%2Da077%2D4579%2Da7e2%2D60588f250df6 https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful%20Information/Forms/AllItems.aspx?OR=Teams%2DHL&CT=1678120935134&id=%2Fsites%2FVACOPatientAdvocacy%2FHelpful%20Information%2FStaffing%20Guidance&viewid=5c5ec074%2Da077%2D4579%2Da7e2%2D60588f250df6

(4) The SLA transmits the complaint on the same day to the appropriate service line(s) for review. The appropriate service line(s) will communicate a resolution to the Veteran, documenting notes, activities, final resolution, and any applicable attachments within PATS. NOTE: If the complaint includes elements outside of the receiving service lines’ authority or expertise, the SLA should document the entire complaint and route it to the PA to execute the process described in paragraph 5.a.

(a) Veterans Unable to be Reached. Three contact attempts must be made on different days and times of the day to reach a Veteran to address their complaint. With every attempt, a phone message must be left that includes a direct line phone number or extension for the Veteran to reach the appropriate VHA point of contact. Each attempt must be documented in PATS using a new patient contact activity. After the third unsuccessful attempt, the SLA must mail the Veteran a complaint closure notification letter. See Appendix A for additional information. The SLA must resolve the complaint in PATS by documenting that the Veteran was unable to be contacted using a resolution activity and by attaching the complaint closure notification letter.

(b) Complaints Open Past the Designated Timeframe. For those complaints unable to be appropriately closed by the designated timeframe, a follow-up call must be made to the Veteran providing a status update, and the call must be documented in PATS as a patient contact activity. NOTE: OPA has designated timeframes for specific types of complaints. Additional information can be found on the PATS Resource Page of the OPA SharePoint:

https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful%20Information/For ms/AllItems.aspx?OR=Teams%2DHL&CT=1678120935134&id=%2Fsites%2FVACOPa tientAdvocacy%2FHelpful%20Information%2FStaffing%20Guidance&viewid=5c5ec074 %2Da077%2D4579%2Da7e2%2D60588f250df6. NOTE: This is an internal VA website that is not available to the public.

(5) Upon receiving the resolution activity response from service line personnel, the SLA must review the documentation for completeness, attach any final documents, accept the resolution and route the action to the Patient Advocate.

(6) Upon receiving the resolution activity response from the SLA, the Patient Advocate must review the documentation for completeness (e.g., ensuring the resolution responds to the complaint; patient contact(s) are documented; applicable attachments are included), assign the most accurate issue code and close the complaint in PATS.

4. PATIENT ADVOCATE TRACKING SYSTEM DATA ENTRY, INFORMATION AND

ANALYSIS

a. PATS Documentation Quality Standards.

(1) Complaints must be documented in PATS in a manner that provides a comprehensive understanding of the complaint to improve the ability of service lines to fully address the complaint on the first attempt. Documentation must be clear, concise and relevant to the issue.

Attachment D.17 RFP 36C24224R0049 https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful%20Information/Forms/AllItems.aspx?OR=Teams%2DHL&CT=1678120935134&id=%2Fsites%2FVACOPatientAdvocacy%2FHelpful%20Information%2FStaffing%20Guidance&viewid=5c5ec074%2Da077%2D4579%2Da7e2%2D60588f250df6 https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful%20Information/Forms/AllItems.aspx?OR=Teams%2DHL&CT=1678120935134&id=%2Fsites%2FVACOPatientAdvocacy%2FHelpful%20Information%2FStaffing%20Guidance&viewid=5c5ec074%2Da077%2D4579%2Da7e2%2D60588f250df6 https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful%20Information/Forms/AllItems.aspx?OR=Teams%2DHL&CT=1678120935134&id=%2Fsites%2FVACOPatientAdvocacy%2FHelpful%20Information%2FStaffing%20Guidance&viewid=5c5ec074%2Da077%2D4579%2Da7e2%2D60588f250df6 https://dvagov.sharepoint.com/sites/VACOPatientAdvocacy/Helpful%20Information/Forms/AllItems.aspx?OR=Teams%2DHL&CT=1678120935134&id=%2Fsites%2FVACOPatientAdvocacy%2FHelpful%20Information%2FStaffing%20Guidance&viewid=5c5ec074%2Da077%2D4579%2Da7e2%2D60588f250df6

(2) Names or portions of names of Veterans, VA staff or other individuals must not be included in free text description boxes in PATS. Names can be added in the involved party section of PATS. Involved party entries must include a name and position title/affiliation.

(3) Documentation should be free from profanity and inappropriate language (even if stated by the Veteran or written in attached correspondence). It should also clearly communicate the Veterans’ perspective and demeanor.

(4) Documentation should include actions taken to inform or educate the Veteran concerning the complaint to establish a basic understanding and manage expectations.

In addition, the documentation should also include the Veterans’ desired resolution.

(5) The method used by the Veteran to contact VHA must be correctly identified.

Complaint origination points include contacts with Veterans and family members, congressional offices, VA Central Office, VA Integrated Enterprise Workflow Solution, correspondence referred through secure email, web-based systems, surveys and other external sources.

(6) Documentation of complaint resolutions must be clear, concise and provide evidence that the issue has been properly addressed.

(7) Any documents provided by or to the Veteran must be attached to the complaint and its resolution in PATS.

b. Handling of Special Incidents.

(1) Abuse, Neglect and Exploitation. Patient Advocates must document allegations in PATS and notify the VA medical facility Patient Advocate Supervisor for proper execution of VA medical facility required reporting activities. See VHA Directive 1199(2), Reporting Cases of Abuse and Neglect, dated November 28, 2017, for additional information.

(2) Assault. Patient Advocates must immediately escort the non-Department individual (Veteran, caregiver, volunteer or visitor) to VA Police. If immediate health care is needed, the Patient Advocate must provide escort to the emergency department. See VHA Directive 5019.02(1), Harassment, Sexual Assaults and Other Defined Public Safety Incidents in Veterans Health Administration, dated September 12, 2022, for additional information.

(3) Discrimination. Patient Advocates must document the incident and transfer the Veteran to the VA medical facility Equal Employment Opportunity Manager to inform the Veteran about the VA Office of Resolution Management (ORM)’s External Complaints Program (ECP) and how to contact ORM for intake on the incident. See VHA Directive 1019, Nondiscrimination in Federally-Conducted and Federally-Assisted (External) Programs, dated May 23, 2013, for additional information. In addition, the Patient Advocate must route the complaint to the appropriate service line for review and action on health care needs that are separate from the ECP.

(4) Harassment. Patient Advocates must document allegations of harassment or sexual assault that have occurred on VA property on behalf of the non-Department individual (Veteran, caregiver, volunteer or visitor) in PATS and execute required VA medical facility reporting activities. See VHA Directive 5019.02(1) for additional information.

(5) Patient Safety. Patient Advocates must document patient safety allegations in PATS and refer the information to the VA medical facility Patient Safety Officer through the Joint Patient Safety Reporting System. See VHA Directive 1050.01, VHA Quality and Patient Safety Programs, dated March 24, 2023.

(6) Privacy Violation. Patient Advocates must document the allegation in PATS and refer the information to the VA medical facility Privacy Officer. See VHA Directive 1605.01, Privacy and Release of Information, dated July 24, 2023.

c. PATS Data Reporting. At a minimum, VISN and VA medical facility Patient Advocacy Offices must report on the following PATS data points:

(1) Total number of cases.

(2) Total number of requests.

(3) Source of complaints.

(4) Average days to close cases (business days).

(5) Average days to resolve requests (business days).

(6) 20 oldest open cases.

(7) Top issue codes (excluding compliments and recommendations).

(8) Top issue codes by overdue status.

(9) Top 5 service lines – timely resolution.

(10) Bottom 5 service lines – timely resolution.

d. PATS Data Privacy.

(1) Data entered in PATS is covered under the Patient Representation Program Records (1300.1) Privacy Act System of Records. As such, the information in PATS is subject to the provisions of VHA Directive 1605.01.

(2) Requests for copies or printing of information in PATS are to be processed in accordance with VHA Directive 1605.01 and are referred to the VA medical facility Privacy Officer or Release of Information Office.

5. MANAGING COMPLAINTS PREVIOUSLY RESOLVED

a. Written Correspondence. In cases where a Veteran has been furnished a written response at least twice from the VA medical facility Director or higher and again initiates a complaint on the same subject, the VA medical facility Director can submit a request to assign a Veteran’s correspondence to a “no reply” status. NOTE: For further information, see VHA Directive 1112, Correspondence Requiring No Response (No Reply), dated September 30, 2020.

b. Other Forms of Receipt. In cases where a Veteran has been furnished a response to a complaint and continues to communicate on the same subject, the VA medical facility Patient Advocate has a responsibility to review the complaint to ensure it has been thoroughly addressed and there are no new issues identified. If there are no new issues identified, the VA medical facility Patient Advocate must notify the Veteran the complaint has been previously resolved, review the resolution specifics, and inform them the new complaint will be closed. If the Veteran does not agree with the response, they should be informed that they may submit the complaint in writing to the VA medical facility Director. If a new issue is identified, only the new issue will be routed to the service line for action.

6. EXTERNAL ADVOCACY GROUPS AND PATIENT REPRESENTATIVES

a. External Advocacy Groups. External advocacy groups are stakeholders who are external to outside of the Federal government, such as congressionally chartered Veterans organizations, VSOs, representatives of State protection and advocacy systems and legal service clinics. If requested, VA medical facilities can allow these groups to:

(1) Post information in a designated location on available services, resources, and support for Veterans.

(2) Place informational brochures in a designated location communicating contact information, available services, resources, and support for Veterans in accordance with 38 C.F.R. § 1.218(a)(9).

(3) Use VA space to hold informational meetings or events in support of Veterans.

VA medical facility space needs shall take priority over these requests. Veteran attendance at such events is strictly voluntary.

b. External Patient Representatives. External Patient Representatives are individuals who are external to VA who support Veterans in gathering information and informing them of health resources and options available to them. If requested, VA medical facilities can allow these individuals to:

(…