D.17 WOMEN VETERANS' HEALTH CARE 36C24423R0132.pdf

WOMEN VETERANS' HEALTH CARE

MCP 400-11

VA MEDICAL CENTER 595 Rescinded Document:

Lebanon, PA 17042 MCM 400-11, Women Veterans’

Health Care, February 18, 2018 Signatory Authority:

Lebanon VA Medical Center Director Effective Date:

February 1, 2021 Responsible Owner:

Women's Veteran Program Manager Recertification Date:

February 28, 2026

1. POLICY

The purpose of this medical center policy (MCP) is to provide equal access and optimal health care to all eligible women Veterans.

2. JUSTIFICATION

To specify policy and procedures to be followed for providing comprehensive quality health care to eligible women Veterans at the Lebanon Veterans Affairs (VA) Medical Center, and VA Community Care Clinics (VACC).

3. RESPONSIBILITIES

a. The Director will appoint a Women Veterans Program Manager (WVPM) for the Lebanon VA Medical Center and VACCs to provide oversight of all women Veterans’ programs.

b. The Chief of Staff has overall responsibility for ensuring that quality care is provided to women Veterans.

c. The Associate Chief of Staff of Primary Care, or designee is responsible for care provided to female Veterans in the Primary Care area.

d. The WVPM is responsible for:

(1) Advocating and responding to the needs and concerns of female patients.

(2) Providing adequate educational activities for staff in the area of women's health issues.

(3) Compiling statistics for reporting on a monthly and quarterly basis.

February 1, 2021 MCP 400-11

e. The VACC Women’s Health Liaison is responsible for working with the WVPM to facilitate patient related issues.

f. The ACOS/Clinical Manager for the admitting care line, or designee, is responsible for Female Veterans receiving complete physical examinations upon admission to the Lebanon VA Medical Center.

g. The Centralized Business Office (CBO) is responsible for the determination of legal eligibility of female Veterans.

h. The Social Worker for Primary Care is responsible for assessing the psychosocial needs of female Veterans. Referrals to shelters for battered or homeless women, or other agencies will not be at VA expense.

i. Environmental Management Service (EMS) is responsible for providing pajamas and robes appropriate for female Veterans.

4. OTHER PARAGRAPHS

PROCEDURES

a. Gender Related Services

(1) Physical examinations. The Women's Health Clinic has been established to provide comprehensive primary care including, gynecological examinations, breast examinations, pap smears, and pelvic examinations for female inpatients and outpatients, as well as providing general medical care for women Veterans.

(2) All women Veterans are offered preventive health screening examinations including breast, pelvic, pap smear, and rectal examinations either in the Women's Health Clinic, or in the individual patient's Primary Care Clinic by a designated Women's Health Provider.

(3) The Women's Health Clinic is staffed by an Interdisciplinary Primary Care Team. This Team consists of a gynecologist and/or a Primary Care physician with expertise in Women’s Health Care, physician extender, Registered Nurse (RN) care manager, Clinical Pharmacist and nursing personnel.

(4) Specialty services such as gynecology, urology, oncology, surgery, psychology, and psychiatry are available upon referral.

b. Mammograms. Mammography services are available to all women. Mammography will be done in accordance with guidelines established by the American Cancer Society (ACS) Breast Cancer Screening Recommendations. Refer also to MCP 400-32, "Screening for Breast Disease.” All mammograms will be ordered on fee for services basis at an accredited facility. All orders for mammograms will include screening for breast implants so that the performing facility is able to provide appropriate screening technique.

c. Screening for Sexual Trauma

(1) The Interdisciplinary Treatment Team consisting of attending physician or physician extender, (WVPM), and/or nursing staff will screen female patients regarding sexual trauma.

(2) If the patient has been the victim of sexual trauma, counseling is arranged by contacting the WVPM, who arranges sexual trauma counseling. In the absence of the WVPM, the RN care manager or Provider in Women’s Health Clinic will contact the Military Sexual Trauma Coordinator to arrange sexual trauma counseling.

d. Privacy

(1) A female chaperone will be present during routine physical examinations, when requested, and always during breast and pelvic examinations, regardless of the gender of the provider.

(2) Complete physical examinations will be performed only in private examining rooms equipped with the necessary provisions to ensure privacy. At the minimum, this will include appropriately sized privacy curtains in all areas. Examination tables in outpatient examination rooms used by women patients will be positioned in such a way that the exam table is not visible from the doorway.

(3) Women inpatients will be assigned to single rooms with private toilet facilities whenever possible; otherwise, assignment will be to multi-bedrooms occupied only by other women. Toilet facilities will be shared only by other women inpatients.

(4) Hospital clothing (i.e., pajamas and robes) in sizes and styles appropriate for women, ensuring privacy will be available on each unit. Units may obtain women's hospital clothing from Environmental Management Service (EMS).

(5) The WVPM is an active participant in the planning and design review process for facility construction and renovation projects to ensure adequate privacy for all female patients.

(6) The WVPM is a member of the Environment of Care (EOC) Committee and participates in EOC rounds weekly to ensure privacy for women Veterans throughout the hospital and the VACCs.

e. Education

(1) The WVPM works with the medical center Patient Education Committee to ensure patient education needs of women Veterans are being met.

(2) The WVPM is responsible for providing continuing medical educational opportunities for medical center house staff and providing staff with at least two

Continuing Medical Education (CME) programs concerning women's health issues per year.

(3) Primary Care providers who provide care to women Veterans will demonstrate to the ACOS, Primary Care, knowledge of gender-specific health care issues, as well as ability to perform appropriate examinations.

(4) Quality Assurance. Quality indicators to monitor aspects of women Veterans' health care are established by the WVPM in collaboration with Primary Care Leadership and Performance Improvement Specialist. Such indicators include patient satisfaction, breast cancer screening, cervical cancer screening, and the timeliness of notification of results. The WVPM is responsible for submitting quality assurance reports to Medical Staff Executive Board (MSEB) on a quarterly basis and to the Primary Care Performance Excellence Council (PEC) on a quarterly basis.

5. REFERENCES

a. Current VHA Directive 1330.01, Health Care Services for Women Veterans- Portions 8, 10, 11, 14, 16, 18, 19, 20 and 24, amended June 29, 2020.

b. Current VHA Directive 1330.02, Woman Veterans Program Manager, dated

August 10, 2018.

c. Current MCM 400-32, Screening for Breast Disease, dated April 30,2019.

d. American Cancer Society (ACS) Breast Cancer Screening Recommendations

6. RESCISSION

MCP Number 400-11, Women Veterans’ Health Care, dated February 18, 2018, is rescinded.

7. REVIEW

This MCP must be reviewed at minimum at recertification, or when notified of National Policy mandates, Handbook/Directive/Notice updates/rescissions or when any changes are necessary in the interim to ensure facility compliance. Necessary changes include local, VISN and national changes.

8. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of February 2026. This MCP will continue to serve as local policy until it is recertified and rescinded.

In the event of contradiction with national policy, the national policy supersedes and controls.

9. SIGNATORY AUTHORITY

X Robert W. Callahan, Jr.

Director

Date Approved:

NOTE: This signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: MCPs are available at:

https://dvagov.sharepoint.com/sites/VHALEB/QualityManagement/MCMs/SitePages/Ho me.aspx https://dvagov.sharepoint.com/sites/VHALEB/QualityManagement/MCMs/SitePages/Home.aspx https://dvagov.sharepoint.com/sites/VHALEB/QualityManagement/MCMs/SitePages/Home.aspx