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Appendix K
VA Monitoring Instrument for
Appropriate Medical Care
VHA DIRECTIVE 96-051 (August l4, 1996)
PERSIAN GULF VETERANS
The mission of the Persian Gulf (PG) Veterans Program is to provide strategic
direction for the clinical, research, education and outreach programs for PG
veterans. This is accomplished by working in collaboration with other VA
offices; Federal, state, and local government agencies; and nonprofit community
and private providers. The Persian Gulf Veterans Program also serves as
VHA's liaison to the Persian Gulf Veterans Interagency Coordinating Board.
Population Measures
1. Waiting time for appointment for Registry examination and referral center
. .
a' mission.
GOAL: <30 days in 95% of VAMCs
2. Education
a. Provide opportunities for continuing medical education of Persian Gulf
War (POW) health issues
GOAL: National Training Program
(l) Onsite conference (8127-8/28)
(2) Teleconferences (satellite video broadcasts) Two in l 996
b. Provide current information on POW programs, legislation, reports and
publications.
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ADEQUACY OF THE VA PERSIAN GULF REGISTRYAND UCAP
GOAL:
Quarterly mailouts and newsletter, periodic Environmental
Agents Services (EAS) conference calls
3. Future POW veteran satisfaction with VA healthcare.
GOAL: Satisfaction > other veteran groups
Program Measures
Waiting times for appointments for consultations, e.g., neurology,
rheumatology, gastroenterology, psychiatry, psychology, etc.
GOAL: =<45 days
2. Persian Gulf Registry: Phase I and Phase II code sheets rejection rates
GOAL: rate=<5°/O
Time to correct rejected code sheets
GOAL: =<30 DAYS
4. Compliance threshold on the annual Quality Management monitor for
Persian Gulf Registry Examinations as measured against selected clinical
indicators
GOAL: 90°/0
Participation rates of Persian Gulf Coordinators and Registry Physicians in
information and educational activities, i.e., quarterly Environmental Agents
Service conference calls, satellite video-television broadcasts, and con-
tinuing medical education conference
GOAL: 75°/0
VHA DIRECTIVE 10-95-114 (November 21, 1995)
PERSIAN GULF REGISTRY HEALTH EXAMINATION
PROGRAM QUALITY MANAGEMENT/SELF
ASSESSMENT MONITOR (TICS 10-0860)
1. PURPOSE: The purpose of this Veterans Health Administration (VHA)
Directive is to provide procedures on use of VA Form iO-9009C-1, Persian Gulf
Registry Health Examination Program~uality Management/Self Assessment
Monitor (Att.~. This instrument has been developed as a quality management
tool for conducting reviews of Persian Gulf War veteran's medical records. It is
to be used by VA medical centers to assess and monitor the appropriateness of
medical care being provided in accordance with the Protocol for conducting the
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APPEND~K
147
Physical Examination and Ordering Diagnostic Studies (M-10, Pt. III, Ch. 2,
App. 2B).
2. BACKGROUND: Approximately 697,000 American servicemen and
service women were involved in the Persian Gulf War. A number of these
troops may have been exposed to environmental hazards, and/or possible
diseases endemic to the Southwest Asia theater of operation.
a. Public Law 102-585, enacted in November 1992, authorized
establishment of the VA's Persian Gulf War Veterans Health Registry. That law
authorized the VA to provide a comprehensive medical examination, including
any diagnostic testing, to evaluate the veteran's health status.
b. An Office of Inspector General (GIG) Report, "An Oversight Evaluation
of the Department of Veterans Affairs' Response to Health Care Issues Relating
to Military Service in the Persian Gulf War" (SHI-A28-011; December 29,
1994), recommended that VA facilities assure that all Persian Gulf War veterans
have been afforded appropriate medical care by conducting peer reviews of a
statistically valid sample of Gulf veteran's medical records.
3. POLICY: VA is committed to providing high quality medical care to
veterans, and to ensure that this goal is met for Persian Gulf War veterans,
appropriate mechanisms must be put in place to address their special needs and
health problems. We also must monitor the effectiveness of the services
provided to them.
4. ACTION
a. Each VA medical center will use the Persian Gulf Registry Health
Examination Program~uality Management/Self Assessment Monitor to re-
view, at least, a 10% sample of all Persian Gulf Registry physical examinations
conducted to date.
b. The first such review will be conducted by each VA medical center
within a time-frame that ensures that results are provided to the Environmental
Agents Program (131), VHA Headquarters, no later than January 31, 1996.
Subsequent reviews should be conducted on an annual basis thereafter, with
results submitted to (131) by October 1 of each year.
c. Results of the review should be recorded on VA Form 10-9009C-2,
Summary Analysis of Self Assessment Monitor Results (Aft. B) for submission
at the following address:
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ADEQUACY OF THE VA PERSIAN GULF REGISTRYANDUCAP
Director, Environmental Agents Program (131)
VHA Headquarters
810 Vermont Avenue, N.W.
Washington, DC 20420
FAX 202-565-7572
d. Questions may be referred to Director, Environmental Agents Program
(131), at 202-565-4183, or Environmental Agents Program staff at 202-565-
4548.
5. REFERENCES
a. M- 10, Part III, Chapters 1 -
b. Office of Inspector General (GIG) Report, "An Oversight Evaluation of
the Department of Veterans Affairs' Response to Health Care Issues Relating to
Military Service in the Persian Gulf War" (SHI-A28-01 1; December 29, 1994~.
6. FOLLOW-UP RESPONSIBILITY: Director, Environmental Agents
Program (13 1), is responsible for the content of this Directive.
7. RECISSIONS: None. This VHA Directive will expire November 21,
2000.
Kenneth W. Kizer, M.D., M.P.H.
Under Secretary for Health
Attachments
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APPENDIX K
ATTACHMENT A
149
PERSIAN GULF REGISTRY HEALTH EXAMINATION
QUALITY MANAGEMENT/SELF ASSESSMENT MONITOR
FACILITY LOCATION (City & State):
FACILITY NUMBER:
PERSIAN GULF COORDINATOR:
VETERANS REGISTRY PHYSICIAN(S):
PATIENT NAME (LAST/FIRST/MI):
PATIENT SSN:
I I I l-m-l I I I I
A. Required Components of the Registry Examination
Yes No
Code Sheet in CHR Consolidated Health Record
1. Thorough History and Physical Examination in Yes No
CHR, such as completion of an SF88
2. Women Tertiary Gulf Veterans
a. Breast Exam
b. Gynecology Exam
3. Laboratory Results in CHR:
a. CBC
b. Chemistries
c. Urinalysis
Yes No Refused
m 0
Yes No
m
Yes No
Yes No
m
Yes No
Refilsed
on
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150
d. Chest x-ray
4. A follow-up visit is recorded?
5. Follow-up letter, containing exam results and Yes No
recommendations is in CHR (or mailed)? m
ADEQUACY OF THE VA PERSIAN GULF REGISTRY AND UCAP
Yes No
m
Yes No NA
6. Additional Diagnostic Work-up for Selected
Symptoms:
The following examinations were ordered by the
physician, if the veteran complained of:
a. Persistent Diarrhea
i. Rectal Exam
ii. Stool guaiac
iii. Stool WBC
iv. Stool for ova/parasite
v. GI consult
b. Memory Loss
Yes No Refilsed
Yes No
m
Ym
Yes No
m
Yes No
m
Yes No
i. Mini-Mental Status Exam or other m
bedside memory test
ii. AdditionalLabs:
Thyroid fimction
Yes No
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vim (~
1
=1
Over gemology consuk, C~j
Sbo~ess of Brew or Cbron1c Cough
L Lung Exam Recorded
ii. Put-ons Func110n Test
iii. Smoking Piston
B. Follow-up Appointments
1. If Me veteran was symp10m~ic ~ We time
of completion of the Registry exam was
How-up exaction scheduled?
Yes No
Yes No
Yes No
Yes No
Yes No
.
Yes No
.
Yes No
2. Has Me veteran been assigned 10 a pram care Yes No
me?
151
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152
ATTACHMENT B
ADEQUACY OF THE VA PERSIAN GULFREGISTRYAND UCAP
SUMMARY ANALYSIS OF SELF-ASSESSMENT MONITOR RESULTS
VAMC/OPC: CITY
1 111 1 111 1 111 1 111 1 111 1 111 1 1 1
VAMC/OPC NUMBER:
1 111
PERSON COMPLETING SURVEY:
STATE:
m
VISN SITE NUMBER:
m
LAST NAME: I I ~ I I I I I I I I I I I I I FIRST NAME: I I I I I I I I
TELEPHONE NUMBER:
AREA CODE
EXTENSION
1 111 1 111 1 111 1 1 111 1
A. BACKGROUND:
1) NUMBER OF PERSIAN GULF VETERANS WHO RECEIVED
REGISTRY EXAMINATIONS IN 19 (STATE YEAR).
2) SAMPLE PERCENTAGE
% Male % Female
m m
B. STANDARD REGISTRY EXAM:
= 1 1 1 10/0
1) NUMBER OF CHARTS THAT CONTA1:NED CODE SHEETS
NON-COMPLIANCE = rT1 l onto
2) NUMBER OF CHARTS THAT CONTAINED A HISTORY
AND PHYSICAL (SF88)
N
1 111 1
N=
1 111 1
N=
NON-COMPLIANCE = I I I l o/o I r I r I
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APPENDIX
3) NUMBER OF CHARTS THAT CONTAINED CBC TEST
RESULTS
NON-COMPLIANCE
= 1 1 1 10/0
4) NUMBER OF CHARTS THAT CONTAINED CHE~STMES
NON-COMPLIANCE
1 1 1 1
5) NUMBER OF CHARTS THAT CONTAINED URINALYSIS
NON-COMPLIANCE
= 1 1 1 10/0
6) NUMBER OF CHARTS THAT CONTAINED COST X-RAY
NON-COMPLL\NCE
= 1 1 1 1%
7) NUMBER OF CHARTS THAT RECORDED A FOLLOW-UP
NON-COMPLIANCE= ~ 1 to
8) NUMBER OF CHARTS THAT CONTAINED A FOLLOW-UP
NON-COMPLIANCE
= I I 1 10/0
C. WORK-UP FOR COMMON COMPLAINTS:
9) NUMBER OF CHARTS THAT CONTAINED SYMPTOM
SPECIFIC EXAMINATIONS IF PATIENT COMPLAINED OF
PERSISTENT DIARRHEA
NON-COMPLIANCE = ~ r T ~ %
1 O) NUMBER OF CHARTS THAT CONTAINED SYMPTOM
SPECIFIC EXAMINATIONS IF PATIENT COMPLAINED OF
NON-COMPLIANCE
153
N=
1 1 1 1 1
N=
1 111 1
N=
1 111 1
N=
1 111 1
N=
-1 1 1
N=
I 1 Eel
N=
I Al I I
N=
= I T I -logo
~ 1 1 1 ~
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154
ADEQUACY OF THE VA PERSIAN GULFREGISTRYAND UCAP
11) NUMBER OF CHARTS THAT CONTAINED SYMPTOM-
SPECIFIC EXAMINATIONS IF PATIENT COMPLAINED OF
SHORTNESS OF BREATH1CHRONIC COUGH
NON-COMPLIANCE
= 1 1 ~ 1%
12) NUMBER OF CHARTS THAT SHOWED A FOLLOW-UP
APPOINTMENT HAD BEEN SCHEDULED
NON-COMPLIANCE = I ~ ~ ~ %
D. PRIMARY CARE TEAM ASSIGNMENT:
13) NUMBER OF CHARTS THAT SHOWED PATIENT HAD
BEEN ASSIGNED TO A PRIMARY CARE TEAM
NON-COMPLIANCE
E. WOMEN VETERANS:
= 1 1 1 1%
14) NUMBER OF FEMALE PATIENT CHARTS THAT SHOWED
COMPLETION OF A BREAST EXAMINATION
NON-COMPLIANCE
= 1 1 ~10/0
15) NUMBER OF FEMALE PATIENT CHARTS THAT SHOWED
COMPLETION OF GYNECOLOGY EXAMINATION
NON-COMPLIANCE
N=
1 111 1
N=
1 111 1
N=
1 111 1
N=
1 111 1
N=
= I T 1 1%
f 1 1 1 1
Representative terms from entire chapter:
gulf registry
