JOINT DoD – MEDCOM CONFERENCE Presentation by The Honorable Paul J. Hutter General Counsel, Department of Veterans Affai

1. JOINT DoD – MEDCOM CONFERENCEPresentation by The Honorable Paul J. HutterGeneral Counsel, Department of Veterans Affairs March 4, 2008

2. Discussion Points • Overview of DoD/VA Legal Relationship • North Chicago: A Federal Healthcare Facility? • Forging an Improved Disability Discharge/Retirement Process • A malpractice case study

3. OVERVIEW • Formal Interactions • Joint Executive Council, e.g., North Chicago/Joint Ventures • Senior Oversight Committee • Interaction on Legislative Proposals, e.g., the Dole – Shalala Commission • Informal interactions are frequent • Information exchange (HIPAA) • Pharmaceutical pricing • National Defense Authorization Act (“Wounded Warrior”)

4. Senior Oversight Committee • First meeting May 8, 2007, weekly meetings until February 2008; now monthly • Created to ensure senior involvement in solving problems associated with Walter Reed • Includes VA Deputy Secretary Mansfield, Undersecretaries for Health and Benefits, Assistant Secretary for Policy • Co-chaired by Deputy Secretary England, includes Service Secretaries, Chiefs of Staff and Director of the Joint Staff

5. Senior Oversight Committee • Eight Lines of Business • Disability System • TBI/PTSD • Case Management • Dod/VA Data Sharing • Facilities • Clean Sheet Design • Legislation and Public Affairs • Personnel, Pay and Financial Support

7. Vision - Creating the future of federal healthcare through excellence in world-class patient care, customer service, education and research. Mission - We are the premier Federal Health Care Center, proud to provide comprehensive, compassionate, patient-centered care to our veterans and DOD beneficiaries while supporting the highest level of operational readiness. l FHCC Vision & Mission

8. = Management authority through Resource Sharing Agreement (RSA) = Operational Line of Authority = Communication and RSA Compliance = Military Reporting Relationship & Accountability FHCC Governance Joint Executive Council (JEC) Health Executive Council (HEC) Joint Facilities Steering Group (JFSG) Advisory Board VHA BUMED VISN 12 NME FHCC SES VA Director Navy 06 Deputy Stakeholders Advisory Council Patient Services Facility Support Clinical Care Dental Services 5/30/07

9. . National Task Groups Legal and Congressional Liaison Joint Health Care Facility Operations Steering Group (JFSG) HR • Personnel Management Model • Governance Model • Beneficiary • Services Leader- ship Finance/ Budget • Finance Model • Organizational • Reporting • EMR Model • AHLTA & • VISTA IM/IT • One Medical Staff Concept • QA information • Sharing Clinical • Property Ownership & • Investment • Model • Logistics & • Procurement • Systems • Analysis Communi-cations • Internal & External Marketing Strategy Admin

10. Executive Decision Memoranda (Starting Point for Legislation) Transfer of personnel Facilities ownership Beneficiary services Pharmacy Fund allocation Other health insurance l FHCC Vision & Mission

11. Milestones Timeline FHCC EDMs Presented to JFSG (15 Jan ’08) All Critical EDMs Ready for HEC/JEC May ’09 FHCC Advisory Board (Assembled) April ’08 FHCC CONOPS Nov ’09 Executive Sharing Agreement April ’09 FHCC 2010 Business Plan Fall 2010 FHCC activated Mar ’08 All Policy EDMs completed May ’09 FHCC Implementation Plan LTG rev 12/5/07

12. DES Pilot Procedures Guide Concept Test a new DoD and DVA disability system…that…eliminates the duplicative, time-consuming, and often confusing elements of the two current disability processes of the departments…

13. DES Pilot Timeline Overview MEB Processes VARating Decision Treatment PEB Processes Transition Seamless Transition Informal Board (15 days) Single Rating Agency Return to Duty Formal Board (30 days) Proposed Rating (15 days) Single Comprehensive Physical: Service member becomes injured or ill OR VA benefits first day of calendar month following month of separation Physical Exam (30 days) Case Development (30 days) Rating Reconsideration (15 days) Appeal (30 days) • Separate: • PDRL • TDRL • Separate w/severence • Separate w/o severence Dr. assesses and treats illness or injury Admin and Record transit (15 days) Admin and Record transit (15 days) 120 days 45 days = 240 days Up to 1 year 75 days

14. DES Pilot Procedures Guide Scope Includes the processing and possible transition to the DVA of members who enter the DoD disability evaluation system…from the Army, Navy, and Air Force…it does not include clinical care except with regard to how the length or nature might impact the design of the DES and associated DVA processes

15. LOA 3 What We’ve done Disability Evaluation System Pilot training was conducted with over 55 NCR PEBLO’s/MSC’s and Patient Admin personnel on 14 – 16 November. Training covered several topics including: • Brief Pilot Background • Data collection • Step by step WII scenario • Tactical communications strategy • Pilot officially began in the NCR November 26th

16. “Right Care, Right Time, Right Place” Recovery MTFs VAMC Private Facilities Military Service Command, Clinical and Non Clinical Multidisciplinary Team WII and Family Centered Federal Individual Recovery Plan (FIRP) Developed with Multidisciplinary Team Federal Recovery Coordinator oversees FIRP Rehabilitation Return to Duty Military Service Tracks Fit Theatre System of Care • Reintegration • Civilian Life • Education, Training • Employment Services • Family Support VA Supports TPA Assigned Military Service Tracks Federal Recovery Coordinator modifies/oversees FIRP Medically Retired VA Supports TPA Assigned Military Service Tracks Federal Recovery Coordinator modifies/oversees FIRP Not Fit DOD Clinical/Non-Clinical Interdisciplinary Team Input and Service for FIRP VA Clinical/Non-Clinical Interdisciplinary Team Input and Service for FIRP Federal Recovery Coordinator Oversees Federal Individual Recovery Plan Federal Individual Recovery Plan, My E-Benefits, Resource Directory, Family Handbook HHS/PHS Support Federal Recovery Coordination Program

18. Medical Malpractice Case Study Facts • Small Medical Center, remotely located from headquarters • Services to 44,000 veterans annually, 7949 surgical procedures over 2 years • JCAHO/OIG visits within 18 months – no major issues • National Surgical Quality Improvement Program picked up outlier – higher than expected mortalities • Reported to OIG/Office of Medical Inspector • Determined 9 deaths from breach of standard of care • 10 deaths unrelated to breaches of care • 24 complications due to substandard care

19. Medical Malpractice Case Study Actions • Transferred leadership immediately • OIG and OMI reviews • Review of HR/EEO/No Fear Act issues • Town Hall meetings with employees simultaneous with Congressional briefings and press releases • OGC review of individual files in conjunction with medical teams • Notification of patients/families by joint medical/OGC teams • 17 tort claims filed • Currently under investigation

20. Medical Malpractice Case Study Take Aways • Vigilant analysis by all interested parties in statistical anomalies • Review EEO and morbidity results for trends • Small facilities may be insulated and isolated; probably require heightened awareness • Prompt and thorough investigation • Transparency and forward outreach based on results

21. Questions and Comments