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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. 145

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146 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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148 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