D.5. VHA Directive 2006-041 - Veterans' Health Care Service Standards.pdf

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THIS VHA DIRECTIVE EXPIRES JUNE 30, 2011

Department of Veterans Affairs Veterans Health Administration Washington, DC 20420

VHA DIRECTIVE 2006-041

June 27, 2006

VETERANS HEALTH CARE SERVICE STANDARDS

1. PURPOSE: This Veterans Health Administration (VHA) Directive provides the policy for promoting and supporting a unified and comprehensive set of Veterans Health Care Service Standards (VHSS). NOTE: This is in compliance with the requirements of Executive Order 12862, entitled "Setting Customer Service Standards," which calls for agencies to post customer service standards and measure results against those standards.

2. BACKGROUND: VHA's mission is to provide patient-centered health care that is comparable with, or better than, care available in the non-Department of Veterans Affairs (VA) sector. It is essential that veteran patients view VA as the best place to receive their health care and that VHA becomes their provider of choice.

a. Executive Order Number 12862, Setting Customer Service Standards, dated September 11, 1993, called for Federal agencies to change how they do business by focusing on customer service. As part of the second phase of reinventing government, a Presidential Memorandum for Heads of Executive Departments and Agencies was issued on March 22, 1995, emphasizing the continuation of Government-wide efforts to integrate and restructure activities in order to improve customer service. The memorandum further directs that achieved results should be reported to the Agency’s customers.

b. In order to accomplish this objective, VHA created thirteen service standards derived from veteran-reported priorities for service covering both inpatient and outpatient care. These standards are intended to provide direction to all VHA Veterans Integrated Service Networks (VISNs) and facilities to ensure that the highest quality care and services are made available to veterans, and by extension, their families and/or significant others.

c. The specific goal that applies to this Directive within VHA’s mission and vision is: “To continuously improve veteran and family satisfaction with VA care by promoting patient-centered care and excellent customer service.” Within this goal, the standards are:

(1) Staff Courtesy. VHA designs and maintains a health care environment where all veterans, their families, and significant others are treated with courtesy and dignity throughout every aspect of their treatment.

(2) Access and Timeliness. VHA provides veterans with timely and convenient access to health care.

(3) One Provider. One health care team is in charge of each patient’s care.

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(4) Respect for Patient Preferences. VHA involves patients, their families, and significant others in decisions about the patient's health care.

(5) Physical Comfort. VHA strives to meet its patients’ pain management and physical comfort needs.

(6) Emotional Needs. VHA provides support to meet its patients’ emotional needs.

(7) Overall Coordination of Care. VHA takes responsibility for providing seamless coordination of its patients’ care within other VA offices, as well as in non-VA facilities and organizations.

(8) Patient Education. VHA provides written and oral information and education about veterans’ health care that all veterans, their families, and significant others will understand.

(9) Family Involvement. VHA provides the opportunity to involve veterans’ families and significant others in the veterans' care when appropriate.

(10) Transition. VHA provides a smooth transition between veterans’ inpatient and outpatient care.

(11) Specialty Care. VHA provides veterans with timely and convenient access and referral to necessary specialist health care.

(12) Pharmacy Service. VHA provides veterans with timely and convenient access to pharmacy services both at the facility and through the Consolidated Mail Outpatient Pharmacy

(CMOP).

(13) Visit Coordination of Care. VHA provides seamless coordination of all aspects of each episode of care.

NOTE: The preceding standards are to be used by each Network in developing a Network-level plan and should be the basis for which periodic assessments are made regarding the accomplishment and achievement of local veterans’ health care service initiatives.

d. The following National Timeliness Goals are in accordance with VHA's strategic Mission and Vision:

(1) Patients must have access to telephone care 7 days-per-week, 24 hours-a-day.

(2) New patients desiring routine care, must be scheduled as soon as possible, and within 30 days.

(3) Patients must be seen by a provider within 20 minutes of their scheduled appointment.

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(4) Patients must be able to schedule a routine follow-up appointment with their primary care provider within 30 days.

(5) Patients must be able to schedule an appointment with a specialist within 30 days of referral.

(6) Patients must be able to schedule an appointment for a routine diagnostic test within 30 days of referral.

3. POLICY: It is VHA policy to comply with Executive Order 12862 and the Presidential Memorandum for Heads of Executive Departments and Agencies memorandum dated March 22, 1995, by establishing a unified and comprehensive set of standards.

4. ACTION

a. Office of Quality and Performance (10Q). VHA's Office of Quality and Performance is responsible for:

(1) Publishing or making available biannually the monthly inpatient veteran feedback, and quarterly publishing or making available the monthly outpatient veteran feedback survey VHA-wide, Network, and facility-level results. NOTE: To assist Networks in communicating results to veterans, the Office of Quality and Performance Web page at http://vaww.opq.med.va.gov can be used to create customer-friendly reports suitable for posting on bulletin boards or other publications designed for veterans and their families. Networks are encouraged to use the most appropriate and effective means possible to ensure that their patients understand and are aware of their facilities progress in meeting and exceeding VHA’s standards.

(2) Working with the Office of the Deputy Under Secretary for Health for Health Operations and Management (10N) to ensure that elements contained in the strategic initiatives, performance measures, and performance monitors are considered for inclusion in the Surveys of the Health Experiences of Patients (SHEP).

b. VISN Director. The VISN Director, or designee, is responsible for ensuring that:

(1) The VISN integrates VHSS into the Network Strategic Plan and the appropriate timeliness goals are met (see subpar. 2d).

(2) The standards are the basis for which periodic assessments are made regarding the accomplishment and achievement of local standard initiatives and the coordination of all aspects of each episode of care (see subpar. 2c). NOTE: Each VISN needs to communicate to veterans, in language they can easily understand, each facility’s current level of compliance with each of the standards. These standards and local timeliness goals should be incorporated. It is very important that each Network and the facilities tailor the national timeliness goals to their unique setting (e.g., long-term care facility versus a tertiary referral hospital; rural versus urban considerations; or other mission-specific standards, needs, or local customs). VHA’s timeliness http://vaww.opq.med.va.gov/

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goals need to be consistent with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements as they relate to patient rights and patient responsibilities.

c. Facility Director. The facility Director is responsible for reporting the results of the facility's performance in the VHSS to patients, and for posting those results at the facility, at least annually in a language readily understood by patients and their families. The results need to delineate the facility's achievements and areas for improvement, as well as any action plans to improve patient services. NOTE: Posting of results can be in the form of storyboards, newsletters to patients, and/or any other appropriate means.

5. REFERENCE: Presidential Memorandum for Heads of Executive Departments and Agencies, dated March 22, 1995.

6. FOLLOW-UP RESPONSIBILITY: The Office of Quality and Performance (10Q) is responsible for the contents of this Directive. Questions may be addressed to (919) 993-3035.

7. RESCISSION: VHA Directive 2001-006 is rescinded. This VHA Directive expires June 30, 2011.

Jonathan B. Perlin, MD, PhD, MSHA, FACP Under Secretary for Health

DISTRIBUTION: CO: E-mailed 6/29/2006 FLD: VISN, MA, DO, OC, OCRO, and 200 – E-mailed 6/29/2006