D.17 VHA Directive 1330.02 Woman Veterans Program Manager.pdf

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Department of Veterans Affairs Veterans Health Administration Washington, DC 20420

VHA DIRECTIVE 1330.02

Transmittal Sheet

August 10, 2018

WOMEN VETERANS PROGRAM MANAGER

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive describes the duties and responsibilities of health care professionals who perform the duties of Women Veterans Program Managers (WVPMs) and Veterans Integrated Service Network (VISN) Lead WVPMs.

2. SUMMARY OF MAJOR CHANGES: Major changes include:

a. Further clarifying the roles and duties for VISN Lead and facility WVPMs and their roles in coordinating activities throughout VISNs, with respect to the level of reporting authority and access to senior facility leadership.

b. Recommending the addition of an Assistant WVPM, as needed, to health care systems that are complex with multiple community-based outpatient clinics (CBOCs), have 10,000 or more unique women Veteran users, anticipate a higher projected number of women Veterans, have an expansive geographic distance between sites, and rurality.

3. RELATED ISSUES: VHA Directive 1330.01, dated February 15, 2017.

4. RESPONSIBLE OFFICE: The Chief Consultant, Women’s Health Services (10P4W), is responsible for the contents of this directive. Questions may be referred to Women’s Health Services at 202-461-0373.

5. RECISSIONS: VHA Handbook 1330.02, Women Veterans Program Manager, dated March 23, 2012, is rescinded.

6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of August 2023. This VHA directive will continue to serve as national VHA policy until it is recertified or rescinded.

Richard A. Stone, M.D.

Executive in Charge

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: E-mailed to the VHA Publication Distribution List on August 16, 2018.

August 10, 2018 VHA DIRECTIVE 1330.02 i

CONTENTS

WOMEN VETERANS PROGRAM MANAGER

1. PURPOSE

2. BACKGROUND

3. DEFINITIONS

4. POLICY

5. RESPONSIBILITIES

6. REFERENCES

WOMEN VETERANS PROGRAM MANAGER

1. PURPOSE

This Veterans Health Administration (VHA) directive establishes the requirements for health care professionals appointed as Women Veterans Program Managers (WVPM) and Veterans Integrated Service Network (VISN) Lead WVPMs. It outlines the duties and responsibilities for WVPMs and VISN Lead WVPMs who are responsible for planning, executing, monitoring, and evaluating the Women Veterans Program services at the local level. AUTHORITY: Title 38 United States Code (U.S.C.) 7301(b); Public Law 102-585.

2. BACKGROUND

a. The WVPM leads the Women Veterans Program at the local facility and works to ensure that timely, equitable, high-quality, comprehensive health care services are provided in a sensitive and safe environment. The program constitutes the delivery of all services for women Veterans, including health care, provided at each VA site of care.

b. In 2008, the Deputy Under Secretary for Health Operations and Management released guidance that designated the position of the Women Veterans Program Manager as a full-time administrative position without collateral assignment with a maximum allotment of clinical time (one-eighth full-time equivalent (FTE) employee) to maintain licensure where warranted.

c. The Government Accountability Office (GAO) Report 2010, VA Health Care Services for Women Veterans (GAO-10-287), concluded that VA has taken steps to make services available to women Veterans, but needs to revise key policies and improve oversight processes. GAO recommended that VA update its policies to clarify the roles and responsibilities of the full-time WVPM position, particularly with regards to the level of reporting authority and access to senior facility leadership. VA adopted this recommendation. In addition, VA assigned program management responsibilities for full-time WVPMs as well as specific duties for full-time VISN Lead WVPMs.

d. The Government Accountability Office (GAO) Report 2016, VA Health Care:

Improved Monitoring Needed for Effective Oversight of Care for Women Veterans, (GAO-17-52), concluded that VA has made progress in providing access to a primary care provider specially trained in women’s health care; however, there are still concerns that VHA may not be fully meeting the health care needs of women Veterans.

3. WOMEN VETERANS PROGRAM

a. VISN Lead Women Veterans Program Manager. The VISN Lead WVPM must be a licensed health care professional and have health care management experience or training. NOTE: A facility WVPM cannot be both the facility WVPM and VISN Lead WVPM at the same time.

(1) The VISN Lead WVPM must dedicate:

(a) Minimum of 0.5 full-time employee (FTE) to women’s health; and

(b) Appropriate clinical hours for licensure.

(2) The VISN Lead WVPM has direct access to senior management in the VISN and serves on executive level administrative and clinical boards or committees affecting any aspect of the care of women Veterans and serves as a vital resource and advisor for programmatic, clinical, capital assets, and/or other crucial women Veterans needs and inquiries. The VISN Lead WVPM reports directly to the Network Director or Chief Medical Officer.

b. Facility Women Veterans Program Manager. The facility WVPM must be a licensed health care professional and/or have health care management experience or training. NOTE: A facility WVPM cannot be both the facility WVPM and VISN Lead WVPM at the same time.

(1) The facility WVPM must dedicate 1.0 full-time employee (FTE) to women Veteran’s programmatic activities

(2) Appropriate clinical hours for licensure

(3) The facility WVPM must have a minimum of 3 years of progressive experience in women’s health demonstrating knowledge and expertise in leadership and program management

4. POLICY

It is VHA policy the VISN Lead WVPM and facility WVPM function as subject matter experts (SME) to provide leadership and oversight that ensures implementation of equitable services for eligible women Veterans.

5. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for ensuring overall VHA compliance with this directive.

b. Deputy Under Secretary for Health for Operations and Management. The Deputy Under Secretary for Health for Operations and Management is responsible for:

(1) Communicating the contents of this directive to each VISN.

(2) Ensuring that each VISN Director has sufficient resources to fulfill the terms of this directive in all the VHA medical facilities within that VISN.

(3) Providing oversight of VISNs to ensure compliance with this directive, relevant standards, and applicable regulations.

c. Chief Consultant, Women’s Health Services. The Chief Consultant, Women’s Health Services, is responsible for:

(1) The management, administration, technical aspects, program planning, guidance evaluations, integration, and implementation of national Women’s Health Program activities (e.g., comprehensive health, education, reproductive health, and others).

These activities include clinical services evaluation and coordination of women Veterans’ health care, epidemiology, and research. Women’s Health Program activities also include initiatives related to other women Veterans’ health issues as defined by VA on an evolving and as-needed basis.

(2) Developing and implementing national directives, program initiatives, and VHA guidance related to women’s health issues, in collaboration with Patient Care Services.

(3) Initiating, promoting, and leading effective collaborations with VISN and facility Directors to integrate the delivery of comprehensive health care services to women Veterans throughout the VA healthcare system and continuously evaluating and improving the delivery of health care to women Veterans.

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

(1) Designating a VISN Lead WVPM to serve as VISN leader on women Veterans needs and as a member of the national Women’s Health Services field advisory group.

(2) Assigning a VISN Lead WVPM to the VISN and at a minimum is a 0.5 full-time employee (FTE) dedicated to women’s health.

(3) Ensuring the VISN Lead WVPM reports directly to the Network Director or Chief Medical Officer, and that the VISN Lead WVPM:

(a) Has VISN-level staff support for data analysis, project implementation, performance improvement projects, as well as resources to ensure equitable and high-quality care of women Veterans; and

(b) Has time to work on sustainable improvements, and performance metrics to effectively grow the women Veterans program across the VISN. NOTE: Any assigned collateral duties must not impede the ability to adequately perform duties to manage the women Veterans program.

(4) Sustaining a multi-disciplinary planning team for comprehensive patient-centered care inclusive of women Veterans at every facility and VISN.

e. VISN Lead Women Veterans Program Manager. VISN Lead WVPM is responsible for:

(1) Leading and coordinating access to equitable, high quality health care and services for women Veterans throughout VISN.

(2) Overseeing the needs of women across the VISN for health care services through:

(a) Identifying gaps and needs through VISN-wide needs assessments, site visits, surveys, and/or other means, including conducting yearly site visits at each facility within the VISN and additional site visits as needed;

(b) Monitoring health care delivery and supporting the initiation of epidemiological and prevalence studies to improve health promotion; and

(c) Monitoring for any disparity in the provision of health care services to women Veterans for performance measures, conducting root cause analyses, overseeing interventions aimed at targeting disparities, and setting up systems for tracking progress related to recommended interventions.

(3) Executing inter-disciplinary comprehensive strategic planning for women’s health at the VISN level that improves the overall quality of care provided to women Veterans and achieves program goals and outcomes, as outlined in VHA Directive 1330.01, Health Care Services for Women Veterans, dated February 15, 2017.

(4) Analyzing data and identifying gaps that limit access and decrease Veteran satisfaction and recommending areas for programmatic or facility improvement.

(5) Serving as a consultant on environment of care compliance issues to ensure all clinical areas meet privacy and safety requirements.

(6) Conducting assessments to identify VA staff education gaps related to women’s health, and developing or adapting educational programs, materials, and resources where gaps are identified.

(7) Developing a VISN-wide education and communication plan to increase awareness of women Veterans’ issues, including increased awareness of VHA benefits and resources to women Veterans and stakeholders.

(8) Monitoring health care delivery and supporting the initiation of epidemiological and prevalence studies to improve health promotion.

(9) Serving as a consultant on women Veterans’ issues for VISN and facility leadership, including:

(a) Serving as a mentor for new VISN Lead WVPMs;

(b) Orienting and ensuring a facility WVPM mentor for newly appointed WVPMs;

(c) Leading monthly calls with WVPMs and Women’s Health Medical Director;

(d) Participate in VISN-level committees to represent women Veterans’ interests;

and

(e) Advocating for WVPMs and women’s health champions at the facility level.

(10) Developing VISN-level women’s health data dashboards that include, but are not limited to, workload, quality measures, access, and cost.

(11) Maintaining knowledge of pertinent women’s health matters through participation in continuing education in women’s health.

(12) Reviewing policies, handbooks, strategic plans, operating plans, and contracts related to women’s health.

(13) Revising existing and developing new women’s health policies, procedures, etc., where needed.

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

(1) Appointing a full-time WVPM to serve as the healthcare system leader on women Veteran’s issues.

(2) Adding an Assistant WVPM, as needed, to augment the Women Veterans Program to ensure the comprehensive health care needs of women Veterans are addressed throughout the system. In absence of WVPM, an Assistant WVPM would also serve as a delegate to provide programmatic coverage. Justifications for adding an Assistant WVPM include, but are not limited to:

(a) Health care systems (HCSs) that are complex with multiple community- based outpatient clinics (CBOCs);

(b) 10,000 or more unique women Veterans;

(c) Higher projected number of women Veterans;

(d) Geographic distance between sites;

(e) Rurality.

(3) Ensuring the WVPM reports directly to the Facility Director or Chief of Staff, and that the WVPM:

(a) Serves on executive administrative and clinical boards and/or committees affecting any aspect of care or potential impact on women Veterans; and

(b) Serves as a vital resource and advisor for programmatic, clinical, capital asset, and other crucial women’s health issues, including input into all construction projects, environment of care, and privacy issues throughout the HCS.

(4) Ensuring that each CBOC has a Women’s Health Clinical Liaison who collaborates with the WVPM at the facility.

(5) Reinforcing culture change initiatives brought forth by the WVPM to better ensure facility staff members appreciate the responsibility of caring for women Veterans.

(6) Ensuring the WVPM participates in any performance improvement initiatives related to local and national performance standards for success in provision of the highest quality services for women.

(7) Ensuring support from appropriate data analysis, quality management, business and finance staff for program management, quality initiatives, and coordination of care.

(8) Ensuring that the name, location, and business telephone number of the WVPM is posted and appropriately publicized in each facility (e.g., on the facility website and accessible through the facility locator web tool).

g. Women’s Health Clinical Liaison. The Women’s Health Clinical Liaison is usually a nurse or social worker, but may be another health care provider. The Liaison is responsible for:

(1) Coordinating women’s health services at CBOCs and independent clinics with the WVPM at the main facility.

(2) Serving as the point of contact who communicates with the WVPM about issues related to women’s health care, environment of care, and policy, and communicating these messages to other staff at the CBOC.

h. Women’s Health Medical Director. The Women’s Health Medical Director (WHMD) must maintain an active clinical practice in Women’s Health. NOTE: It is recommended that the WHMD is a Designated Women’s Health Primary Care Provider (WH-PCP). The WHMD is responsible for:

(1) Serving as the clinical leader for the Women’s Health Program at the facility level.

(2) Working, in collaboration with WVPM, to develop clinical leadership for the Women’s Health Program, including participation in strategic planning, administration, quality improvement, and educational initiatives.

i. Facility Women Veterans Program Manager. The facility WVPM is responsible for:

(1) Leading the overall delivery of care and services for the growing population of women Veterans, including through program management, strategic planning, advocating for women Veterans, cultural transformation, policy on women Veterans, business planning, staff training, environment of care and capital assets, outreach, partnerships with special populations, contracting review, care in the community, and collaboration with services (including diagnostic, emergent and urgent care, primary care, and specialty care).

(2) Providing oversight of the Women Veterans Program and working closely with the Women’s Health Medical Director to form the foundation of the women’s health team at the facility level.

(3) Serving as Chair of the Women Veterans Health Committee at facility level.

NOTE: For more information on the responsibilities of the Women Veterans Health Committee, see VHA Directive 1330.01.

(4) Providing expertise and guidance specific to women Veterans for facility-wide strategic goals and objectives and executing comprehensive planning for women’s health that improves the overall quality of care provided to women Veterans and achieves program goals and outcomes.

(5) Serving as an advocate for women by working closely with Veteran Experience Office (Patient Advocate Office) to facilitate problem resolution and women Veteran satisfaction.

(6) Collaborating with facility leadership on culture transformation to create a safe, secure, and respectful environment for women Veterans to receive care.

(7) Collaborating with facility leadership to ensure local implementation of national policy related to women Veterans and reviewing and providing input on all facility policies as they are created or revised to support the needs of women Veterans.

(8) Collaborating with fiscal and facility leadership to advocate for resources to support programs to meet the needs of women Veterans.

(9) Collaborating with the Education Department and/or Designated Learning Officer to identify and address training needs for facility staff specific to women Veterans, and promoting national and local educational programs for women’s health providers and other staff.

(10) Participating in the review of the physical environment, including:

(a) Identifying deficiencies and opportunities for improvement and work with facility leadership, facility planner, and other staff to ensure that new construction and renovations are appropriate to meet the needs of women Veterans; and

(b) Exercising direct authority to sign off on renovation, construction design and architectural plans.

(11) Collaborating with facility and community stakeholders to develop a comprehensive outreach plan that includes increasing public awareness of services available for women Veterans; networking to enhance community engagement with non-VA stakeholders; and increasing market penetration.

(12) Partnering with special population coordinators and program managers to ensure the needs of women Veterans are addressed across the health care system.

(13) Collaborating with facility leadership and local contracting staff to review applicable facility contracts related to women’s health, including for all CBOCs, health network providers, diagnostics services, as they are created or revised to ensure they meet the requirements that are consistent with national women’s health policy.

(14) Collaborating with facility leadership and internal and external partners to ensure that timely access to necessary care in the community is provided.

(15) Collaborating with facility leadership to ensure that high quality and gender-specific diagnostic services for women are available in a timely manner at all points of care and ensuring processes are in place for timely patient notification and coordination of care as indicated.

(16) Collaborating with various services to ensure the needs of women Veterans are met in a comprehensive manner consistent with national policies, including with:

(a) Emergency care and other leadership to ensure that emergent and urgent care needs of women Veterans are met in a comprehensive manner consistent with national policies;

(b) Primary care leadership and women’s health primary care providers to provide programmatic consultation; and

(c) Surgery service, mental health services, and other specialty care services.

6. REFERENCES

a. 38 U.S.C. 7301(b).

b. Public Law 102-585.

c. VHA Directive 1330.01, Health Care Services for Women Veterans, dated February 15, 2017.

d. United States Government Accountability Office (GAO), GAO-10-287, Report, VA Health Care, VA Has Taken Steps to Make Services Available to Women Veterans, but Needs to Revise Key Policies and Improve Oversight Processes, dated March 31, 2010.

e. United States Government Accountability Office (GAO), GAO-17-52, Report, VA Health Care: Improved Monitoring Needed for Effective Oversight of Care for Women Veterans, dated December 2, 2016.