Analysis of HRPP & RDCP Routine Reviews Calendar Year 2010

1. Analysis of HRPP & RDCP Routine ReviewsCalendar Year 2010 Frequent Findings Aileen Ward and Bob Brooks HRPP 201 Orlando Florida March 24, 2010

2. Routine Reviews • Overview of the Human Research Protection Program (HRPP) and Research & Development Program (RDCP) Reviews • Review of Frequent Findings  • Visit RCO SharePoint Site for document

3. Office of Research Oversight • Public Law 108-170 (38 USC §7307) • Created VHA Office of Research Oversight • Reports directly to Under Secretary for Health • Chief Officer has statutory authority to halt research • ORO findings must be reported to House and Senate Veterans Affairs Committee • Quarterly and Annual Reports to Congress • Copies of ORO Reports

4. Routine Reviews 2010 • 57 HRPP and RDCP Routine Reviews (RR) • 51 in 2009 • 36 VAMC RR of HRPP/RDCP • 28 in 2009

5. Routine Reviews 2010 • 11 ACUP (Animal Care & Use Program) • 5 RSSP (Research Safety & Security Prg) • 17 RIPP (Res Information Protection Prg • 4 BSL-3 (Biosafety Level) • 5 For Cause Reviews (FCR)

6. Routine Reviews 2010 • 21 RR included both HRPP & RDCP simultaneously • 1 w/o findings • 2009 almost all were simultaneous reviews • 11 RR were HRPP alone • 1 w/o findings • 4 RR were RDCP alone

7. Routine Reviews 2010Most Frequently Cited Concerns (All ROs)“Top 10 in 2010” RDCP • The R&DC did not fully satisfy the requirements for annual reviews of subcommittees and research programs. (76%-19/25) • R&DC policies and procedures contained information that was outdated or inconsistent with current VHA policies. (72%-18/25) • The R&DC did not maintain SOPs or other written procedures for all recurring processes. (56%-14/25) • The R&DC and ACOS/R&D did not fully satisfy the requirements of annual quality assurance (QA) reviews of publications, scopes of practice, and CRADAs. (40%-10/25) • The R&DC membership roster was outdated or did not identify the primary member(s) for whom each alternate member may substitute. R&DC meeting minutes did not indicate the name of primary member whom the alternate member is replacing. (36%- 9/25)

8. Routine Reviews 2010Most Frequently Cited Concerns (All ROs)“Top 10 in 2010” continued HRPP • IRB policies and procedures contained information that was outdated or inconsistent with current VHA policies. (53%-17/32) • Research personnel and/or oversight committee members did not complete required training. (38%-12/32) • Research personnel conducted research without a research scope of practice and/or current scopes of practice for all non-privileged research personnel were not retained in the Research Office. (38%-12/32) • The ISO and PO did not thoroughly review research protocols and document their reviews. (31%-10/32) • The informed consent document (ICD or VA Form 10-1086) approved by the IRB did not contain all required elements. (25%-8/32)

9. 1. The R&DC did not fully satisfy the requirements for annual reviews of subcommittees and research programs Review of R&DC meeting minutes and interview with ACOS/R&D and the R&DC Vice Chair revealed that R&DC conducted annual reviews of the VAMC IRB, IACUC, and SRS, but not the VA Central IRB and affiliate IBC. In addition, R&DC did not submit a summary of its review and evaluation of the VAMC R&DC subcommittees to MCD

10. 1. The R&DC did not fully satisfy the requirements for annual reviews of subcommittees and research programs The RDC did not conduct annual assessments that systematically evaluated the research program. For example the following areas were not evaluated: • HRPP and IRB Performance • ACUP and IACUC Performance • The Research Safety Program and SRS Committee Performance

11. 1. The R&DC did not fully satisfy the requirements for annual reviews of subcommittees and research programs Incomplete annual evaluations of subcommittees. The RDC annual evaluations of the IACUC and IRB lack required elements . Specifically, the annual evaluation does not include: a status review of credentialing and training; budgetand space; or review of support staff, qualityimprovement activities, compliance issues, and goals for the next year.

12. 1. The R&DC did not fully satisfy the requirements for annual reviews of subcommittees and research programs Incomplete annual evaluations of subcommittees. The RDC annual evaluations of the IACUC and IRB lack required elements . The annual evaluation of the IACUC lacks: evaluation of the inspection reports; review of the composition and membership of the committee; or consideration of budget, space, support staff, training, quality improvement activities; or review of compliance issues and goals for next year.

13. 1. The R&DC did not fully satisfy the requirements for annual reviews of subcommittees and research programs Incomplete annual evaluations of subcommittees. ….some required elements of these evaluations have not been carried out…. As examples, the evaluation of the IACUC does not include consideration of budget, space, or goals for the year, and the evaluation of the SRS does not include consideration of security issues or planned training.

14. 1. The R&DC did not fully satisfy the requirements for annual reviews of subcommittees and research programs ORO’s review of R&DC meeting minutes and its interviews with personnel did not provide evidence of comprehensive oversight reviews that would have fully satisfied these requirements.

15. 1. The R&DC did not fully satisfy the requirements for annual reviews of subcommittees and research programs. VHA Handbook 1200.01 §9 stipulates that the R&DC is responsible for: b(5) Reviewing and evaluating all R&D subcommittees both within the VA facility and at external entities that function in lieu of R&D subcommittees…. A summary of these reviews and evaluations must be sent to the medical center Director annually; and c(2) Review of subcommittee activities including: • Annual reviews of the Research Safety and Security Program (including planned training, compliance, security issues, etc.); • The Animal Care and Use Program (including inspection reports, IACUC composition, IACUC arrangements, budgets, space, support staff, training, quality improvement activities, compliance issues, and goals for the next year); and • The Human Research Protection Program (including IRB composition or IRB arrangements, credentialing and training status report, budget, space , support staff, quality improvement activities, compliance issues, and goals for the next year).

16. 2. R&DC policies and procedures con-tained information that was outdated or inconsistent with current VHA policies. The R&DC did not develop procedures that allow the Committee to hold unscheduled meetings in response to emergent issues. Specifically, the R&DC SOP stated that R&DC may use an expedited review process when the R&DC Chair deems it appropriate. R&DC minutes reflect that an expedited review process was used on several occasions.

17. 2. R&DC policies and procedures con-tained information that was outdated or inconsistent with current VHA policies. • http://vaww.vha.vaco.portal.va.gov/sites/ORO/RCO/FAQs/Forms/AllItems.aspx). Question: Can a Research and Development Committee (R&DC) give approval contingent on Institutional Review Board (IRB) approval? Response:No. R&DC review may not occur until all the relevant subcommittee approvals occur.  Because there is no provision for expedited R&DC review under Veterans Health Administration (VHA) policy, there is no mechanism for implementing an R&DC contingent approval process.

18. 2. R&DC policies and procedures con-tained information that was outdated or inconsistent with current VHA policies. The SOPs state that: Electronic voting will occur in the event a quorum is lost or when important business requires action prior to the R&DC meeting. Electronic voting approval requires that a quorum of votes be received electronically and that more than 50 percent of the votes cast are for approval.

19. 2. R&DC policies and procedures con-tained information that was outdated or inconsistent with current VHA policies. However, VHA Handbook 1200.01 §11 stipulates that: If physical presence is not possible, a [R&DC] member may be considered through teleconferencing or videoconferencing. Thus, VHA Handbook 1200.01 includes no provision for electronic voting.

20. 2. R&DC policies and procedures con-tained information that was outdated or inconsistent with current VHA policies. The SOPs state that “The Executive Career Field (ECF) Performance Plan states that the RCO will serve as a non-voting member on the Institutional Review Board (IRB), Institutional Animal Care and Use Committee (IACUC), Biosafety Committee, and Research and Development Committee (R&DC).”

21. 2. R&DC policies and procedures con-tained information that was outdated or inconsistent with current VHA policies. The cited ECF Performance Plan was for FY2009. The recently released VHA Handbook 1058.01 (dated May 21, 2010) §4.t stipulates that “In addition to conducting required audits, the RCO may serve as a nonvotingconsultant, …. The RCO may not serve as a voting or non-voting member of these committees.” (See also ORD Guidance at: http://www.research.va.gov/pride/policy/Guidance-RCO-committee.pdf)

22. 2. R&DC policies and procedures con-tained information that was outdated or inconsistent with current VHA policies. …it was stated that “records must be maintained for a minimum of 5 years.” However, VHA Handbook 1200.05 §7.j stipulates that “The required records, including the investigator’s research records, must be retained until disposition instructions are approved by the National Archives and Records Administrations and are published in VHA’s Records Control Schedule (RCS 10-1).” (1200.01 §12.b)

23. 2. R&DC policies and procedures con-tained information that was outdated or inconsistent with current VHA policies. VHA Handbook 1200.01 §12b stipulates that ‘Records are the property of VA and the policy for record retention is outlined in VHA Records Control Schedule (RCS) 10-1.’ Likewise, VHA Handbook 1200.05 §26h stipulates that ‘The required records, including the investigator’s research records, must be retained until disposition instructions are approved by the National Archives and Records Administration and are published in VHA’s RCS 10-1.

24. 2. R&DC policies and procedures con-tained information that was outdated or inconsistent with current VHA policies. The ACOS/R&D who will also serve as the Executive Secretary, and 2. Chairpersons of the subcommittees …. are the R&DC ex officio members with vote.”

25. 2. R&DC policies and procedures con-tained information that was outdated or inconsistent with current VHA policies. However, VHA Handbook 1200.01 §13.f(1) requires that ACOS/R&D be an ex-officio, non-voting member of R&DC and functions as Executive Secretary of the R&D Committee

26. 3. The R&DC did not maintain SOPs or other written procedures for all recurring processes. ORO noted that the R&DC SOP did not include written procedures for some recurring processes, such as responsibilities of the ACOS/R, R&DC, and R&DC evaluation of its subcommittees.

27. 3. The R&DC did not maintain SOPs or other written procedures for all recurring processes. VHA Handbook 1200.01 §11.e requires that R&DC SOPs must be maintained for all recurring processes.

28. 3. The R&DC did not maintain SOPs or other written procedures for all recurring processes. The R&DC Handbook and SOPs did not describe recurring processes. For example, “Administrative Review” and the PO/ISO review and documentation process were not described as required by VA policy.

29. 3. The R&DC did not maintain SOPs or other written procedures for all recurring processes. VHA Handbook 1200.01 §11.e stipulates that ‘Standard operating procedures or other written procedures must be maintained for all recurring processes. These processes include, but are not limited to, communication with the Medical Center Director, the COS, investigators, and committees or subcommittees.

30. 4. The R&DC and ACOS/R&D did not fully satisfy the requirements of annual quality assurance reviews of publications, scopes of practice, and CRADAs. The R&DC did not conduct effective oversight of the research program and make appropriate recommendations to the MCD. Specifically, the VAMC provided no documentation that the R&DC conducted annual evaluations that assessed: ACOS/R&D quality assurance reports including annual assessments of publications, employees involved in human subjects research, and Cooperative Research and Development Agreements (CRADAs), and other agreements in support of the research program.

31. 4. The R&DC and ACOS/R&D did not fully satisfy the requirements of annual quality assurance reviews of publications, scopes of practice, and CRADAs. …the ACOS/R did not conduct an annual quality assurance (QA) review of research staff scopes of practice.

32. 4. The R&DC and ACOS/R&D did not fully satisfy the requirements of annual quality assurance reviews of publications, scopes of practice, and CRADAs Review of R&DC meeting minutes and interview with ACOS/R&D and the R&DC Chair revealed that …neither R&DC nor ACOS/R&D conducted any of the required annual quality assurance reviews.

33. 4. The R&DC and ACOS/R&D did not fully satisfy the requirements of annual quality assurance (QA) reviews of publications, scopes of practice, and CRADAs. VHA Handbook 1200.01 §7.c., 7.d., and 7.f. require the ACOS/R&D to conduct annual QA reviews of publications assessing the acknowledgement of VA support and affiliation; annual QA review of resarch employees regarding scopes of practice and their credentialing and privileges; and annual QA review of CRADA and other agreements in support of the research program.

34. 4. The R&DC and ACOS/R&D did not fully satisfy the requirements of annual quality assurance (QA) reviews of publications, scopes of practice, and CRADAs. 9.c.(1) In fulfilling its responsibilities….the R&DC needs to rely on a variety of information sources including: (1) Quality assurance activities, reports to the committee by the ACOS/R&D, AO/R&D, or other research staff members, subcommittee reports…..

35. 5. The R&DC membership roster was outdated or did not identify the primary member(s) for whom each alternate member may substitute. R&DC meeting minutes did not indicate the name of primary member whom the alternate member is replacing. The VAMC did not have the roster of the SRS committee on site; the RDC roster provided to ORO did not specify the voting status of each member , and the date of membership for the RCO is not accurate. The VAMC RDC roster provided to ORO does not identify whom the alternate member may replace.

36. 5. The R&DC membership roster was outdated or did not identify the primary member(s) for whom each alternate member may substitute. R&DC meeting minutes did not indicate the name of primary member whom the alternate member is replacing. The RDC membership roster did not indicate the primary members whom the alternate members might substitute or were replacing.

37. 5. The R&DC membership roster was outdated or did not identify the primary member(s) for whom each alternate member may substitute. R&DC meeting minutes did not indicate the name of primary member whom the alternate member is replacing. The membership rosters that were provided to ORO were outdated, listing members that were no longer VA employees or no longer members of the committees. …The RDC roster lists two persons who are no longer RDC members. None of the rosters were dated so that correct and current membership for a specific point in time could not be verified.

38. 5. The R&DC membership roster was outdated or did not identify the primary member(s) for whom each alternate member may substitute. R&DC meeting minutes did not indicate the name of primary member whom the alternate member is replacing. VHA Handbook 1200.01 §12.a stipulates that ‘The adequate documentation of all of the activities of the R&DC must be maintained, including but not limited to, the following….(3) Membership lists for the R&DC and all R&DC subcommittees.’

39. 5. The R&DC membership roster was outdated or did not identify the primary member(s) for whom each alternate member may substitute. R&DC meeting minutes did not indicate the name of primary member whom the alternate member is replacing. VHA Handbook 1200.01 §13.c(6) stipulates that ‘The R&DC membership roster must identify the primary member(s) for whom each alternate member may substitute.’

40. 5. The R&DC membership roster was outdated or did not identify the primary member(s) for whom each alternate member may substitute. R&DC meeting minutes did not indicate the name of primary member whom the alternate member is replacing. §11.c(1) …and ‘If an alternate is present in place of a voting member, the minutes need to indicate this fact and name who the alternate member is replacing.

41. 1. IRB policies and procedures contained information that was outdated or inconsistent with current VHA policies. The criteria and timelines for reporting research events in the VAMC IRB SOP are not consistent with VHA Handbook 1058.01 For example, the VAMC SOP requires that when the RCO determines that non-compliance is serious or continuing, a report is to be filed within 10 days to the IRB, the ACOS/R, and the MCD. The VAMC IRB SOP does not accurately reflect procedures or timelines to evaluate the unanticipated problem or SAE as described in the Handbook.

42. 1. IRB policies and procedures contained information that was outdated or inconsistent with current VHA policies. VHA Handbook 1058.01 § 6.a.(4)(b) establishes the required timeline at 5 business days. In addition, VHA Handbook 1058.01 § 6 and Appendix B § 11-13 establishes criteria and timelines for IRB evaluations, determinations and reporting requirements for unanticipated problems and SAEs. The VAMC IRB SOP does not accurately reflect procedures or timelines to evaluate the unanticipated problem or SAE as described in the Handbook.

43. 1. IRB policies and procedures contained information that was outdated or inconsistent with current VHA policies. ….page XXX stated that “The IRB Coordinator serves as the alternate voting IRB, non-scientific, and affiliated member.” However, VHA Handbook 1200.05 §12.j stipulates that “R&D Administration officials including, but not limited to the ACOS for R&D and the AO for R&D, may not serve as voting members of the IRB.” This prohibition extends to IRB Coordinators/Administrators.

44. 1. IRB policies and procedures contained information that was outdated or inconsistent with current VHA policies. On page XXX regarding the storage and dispensing of Investigational Devices and Drugs, it was stated that “The investigator is responsible for storage, security and dispensing of investigational devices and drugs.”

45. 1. IRB policies and procedures contained information that was outdated or inconsistent with current VHA policies. VHA Handbook 1108.04 stipulates that: Regardless of the source, all investigational drugs must be delivered to the Pharmacy Service and/or Research Service Investigational Pharmacy for receipt, storage, security, dispensing, distribution, and disposition. All investigational drugs must remain under the direction of Pharmacy Service.” (§7a)

46. 1. IRB policies and procedures contained information that was outdated or inconsistent with current VHA policies. VHA Handbook 1108.04 stipulates that: The Chief, Pharmacy Service, or Chief (Manager) for the Research Service Investigational Pharmacist may delegate in writing the custody of investigational drugs stored outside the pharmacy to the PI.” (§6a) Thus, in order for the investigator to store and dispense investigational drugs, the Chief of Pharmacy must delegate this authority to the investigator in writing.

47. 1. IRB policies and procedures contained information that was outdated or inconsistent with current VHA policies. The VA IRB SOP statement, “The costs of the non-veteran participants must be absorbed by the study’s sponsoring agency. No costs would be covered by the VA for these participants,”

48. 1. IRB policies and procedures contained information that was outdated or inconsistent with current VHA policies. VHA Handbook 1200.05 32.a.(3)(a) Pursuant to 38 CFR 17.102, subjects in VA-approved research cannot be charged, nor can their insurance be billed, for research-related interventions or procedures (e.g., tests, drugs, clinic visits, hospital admissions, transportation) that are required by the protocol. If medical services are furnished to a person who is not eligible for medical services as a Veteran, the medical care appropriation will be reimbursed from the research appropriation.

49. 1. IRB policies and procedures contained information that was outdated or inconsistent with current VHA policies. The IRB approval letter stated that: “Research records must be retained for three years after completion of the research, if the study involves medical treatment; it is recommended that the records be retained for eight years.”

50. 2. Research personnel and/or oversight committee members did not complete required training. ORO noted that three active research personnel did not maintain mandatory training requirements. Review of Personnel Training Records revealed that 17 out of 239 active research study personnel (7.1%) lapsed in their required trainings. Review of training records revealed that the records were accurate and up-to-date. However, 14 out of 117 active research study personnel (12%) lapsed in their required trainings.