D.46 VHA Directive 1003.04 VHA Patient Advocacy.pdf

Department of Veterans Affairs Veterans Health Administration Washington, DC 20420

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VHA DIRECTIVE 1003.04

Transmittal Sheet February 7, 2018

VHA PATIENT ADVOCACY

1. PURPOSE:

2. SUMMARY OF MAJOR CHANGES:

3. RELATED ISSUES:

4. RESPONSIBLE OFFICE:

5. RESCISSION:

6. RECERTIFICATION:

DISTRIBUTION:

(DATE) VHA DIRECTIVE 1003.04

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CONTENTS

VHA PATIENT ADVOCACY

February 7, 2018 VHA DIRECTIVE 1003.04

VHA PATIENT ADVOCACY

1. PURPOSE

AUTHORITY:

2. BACKGROUND

NOTE: See Appendix A for more information on

PCCC.

3. DEFINITIONS

Caregiver.

NOTE: In the community, outside of VA, Family Caregiver is the term used by most health care organizations and non-governmental agencies to describe family members and/or close friends who serve as non-paid Caregivers. A similar term used is informal Caregiver.

Clinical Appeal.

Complaint.

Complaint Resolution.

External Advocates.

Facility Patient Advocate.

Inquiry Routing and Information System.

Patient Advocate.

Patient Advocacy.

Patient Advocate Tracking System (or a successor system).

Patient-Centered Care.

Patient-Centered Care Coordinator.

Patient-Driven Approach.

Proactive Approach.

Program Model: Centralized.

Program Model: Decentralized.

NOTE: Some programs consist of both centralized/decentralized models and are considered a hybrid model. It is determined by leadership which program model best serves the organization and Veterans.

Report of Contact.

Service-Level Advocate.

Service Recovery.

Significant Patient Complaint.

Site Information Taker System.

Station User Coordinator.

Veteran Experience.

VA Veteran Experience Office.

Veteran/Family Advisor.

Veteran/Family Advisory Council.

4. POLICY

5. RESPONSIBILITIES

Under Secretary for Health.

Deputy Under Secretary for Health for Operations and Management.

Executive Director, Office of Patient Advocacy.

Veterans Integrated Service Network (VISN) Director.

NOTE: Initial documentation of a complaint resolution should occur as soon as possible, but no later than 7 days after initial contact with the Veteran

Veterans Integrated Service Network (VISN), Patient Advocate Coordinator.

NOTE: This allows for effective data analysis across facilities.

VA Medical Facility Director.

NOTE: Resolution and documentation will occur within 7 business days.

VA Medical Facility Patient Advocate.

NOTE: This communication may be through a separate report or the minutes of the quality improvement committee(s).

Patient-Centered Care Coordinator.

Service-level Advocates.

VA Medical Facility Quality Manager.

6. PROGRAM MODEL

Decentralized Model.

Centralized Model.

NOTE: Examples and resources to support the Patient Advocacy Program model are located in Appendix A.

7. DATA ENTRY, INFORMATION, AND ANALYSIS

Data Entry.

Documentation of Complaint.

Entry of Complaints.

NOTE:

Additional instructions for the Patient Advocate Tracking System are located at http://vaww.infoshare.va.gov/sites/OPCC/VEP/default.aspx This is an internal VA Web site that is not available to the public.

VA Records.

Analysis and Reporting.

Satisfaction Data.

NOTE: This is an internal VA Web site that is not available to the public.

Data on IRIS.

NOTE: This is an internal VA Web site that is not available to the public.

8. EXTERNAL ADVOCACY

9. COLLECTIVE BARGAINING

10. TRAINING REQUIREMENTS

11. RECORDS MANAGEMENT

12. REFERENCES

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APPENDIX A

RESOURCES FOR ESTABLISHING A PATIENT ADVOCACY PROGRAM

1. OFFICE OF PATIENT ADVOCACY (10H): SHAREPOINT SITE:

2. OFFICE OF PATIENT CENTERED CARE:

3. VETERAN EXPERIENCE PROGRAM TOOLKIT:

4. VOICE OF THE VETERAN TOOLKIT:

5. PATIENT/FAMILY ADVISORY COUNCIL TOOLKITS:

6. HEALING ENVIRONMENT TOOLKIT:

7. PATIENT ADVOCACY TRACKING SYSTEM ACCESS KEY TOOLKIT:

NOTE: For items 1-6, these are internal VA Web sites that are not available to the public.

8. COMPREHENSIVE ADDICTION AND RECOVERY ACT (CARA):

9. BEREAVED FAMILY SURVEY-INPATIENT:

NOTE: This is an internal VA Web site that is not available to the public.

10. LGBT VCC PROGRAM TOOLS:

11. THE JOINT COMMISSION:

12. PATIENT ADVOCATE TRACKING SYSTEM ISSUE CODES:

13.Rights and Responsibilities of Family Members of VA Patients and Residents of Community Living Centers (CLC) IB 10-284 PDF:

14.Rights and Responsibilities of VA Patients and Residents of Community Living Centers (CLC) IB 10-89, P91985: