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April 2004

### A Publication of Medical - Surgical Services

Pages- Inside This Issue

  ------ ------------------------------- ----- -----------------------------
  1-2    Message: Medical -- Surgical    12    Toni Lawrie Honored
         Services Office                       

  2-5    Medical-Surgical Services       13    2004 Conference Call
         Survey Results                        Schedules

  6      Primary Care Welcomes Dr.       14    Schedule for M-S News
         Gerald Cross, MD.                     Articles

  6-11   Improving The Quality of Care   15    Editorial Board
         Through Improving Colorectal          
         Cancer Screening                      
  ------ ------------------------------- ----- -----------------------------

######### Medical-Surgical Services Survey Results

Mildred Eichinger, RN, MPH

Clinical Program Manager

Medical/Surgical Services Office

Primary Care

On November 8, 2003, Dr. Michael Kussman, Chief Consultant for the
Medical/Surgical Services Office in Patient Care Services, sent out two
memos to the field. The first asking who would be interested in holding
leadership positions and the second, who would volunteer to serve either
as Chairman or member on a newly established Primary Care Field Advisory
Committee? Furthermore, we asked that deterrents be identified and what
could the Medical-Surgery Office do to help. A survey was sent out to
the field asking for input to identify the significant issues that this
office should address. Our thanks to those of you who took the time from
your busy schedules to respond. Based on key word searches some of the
major issues were: Advanced Clinic Access (59), Advance Access (12),
Access (44), Scheduling (11), for a total of 126. In addition, Quality
(30), Specialty Care (27), Tele-health (11), Telemedicine (9), along
with Education (15), Resources (15), Inpatient (11), Integration (10),
Satisfaction (9), CPRS (9), Productivity (8), and Care Coordination (8)
were also identified.

Approximately 125 responses were sent in electronically. The intent of
the survey was to let Dr. Kussman and the Med/Surgery staff know what
the field staff was coping with and what the deterrents there were to
practicing good quality care primary care service and perhaps more
importantly what the Med/Surgical Services Office could do to help.

The following is a summary of the deterrents and issues that were
identified. This was not a scientific survey-but the results provided a
great deal of information that will be used to set the agenda for the
coming months. My thanks to all who took the time to answer our
questions.

There were three questions asked, the following are some quotes from the
responses.

Primary Care Projects

**Question 1. :** Would you be willing to take the lead or serve as a
member of a task force focusing on a particular project? If so, what
project?

**Answers**:

1.  "... utilizing telemedicine for specialty clinics at other
    facilities within the VA so patient does not have to travel so
    frequently."

2.  Projects of interests:

    a.  Advanced Access for both Primary Care and Specialty Care.

    b.  Development of the interface between Primary and Specialty Care
        Services especially as it concerns access, waits and delays.

    c.  Finding ways to improve EPRP performance measure scores and the
        implementation of clinical reminders.

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3.  "Subspecialty clinic access and methodology for primary care budget
    allocation."

4.  Clinical staff doing clinical jobs.

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5.  Development of schedule management guidelines which address
    equitably incorporated ACA high leverage changes, provider ownership
    of assigned panels, processes for overbooks, contingency planning,
    equitable administrative time, PCMM assignments and clinical
    cancellations. Also ... clinical operations Primary Care Maintenance
    Manual.

# Primary Care Deterrents

**Question 2. :** What, from your view, are the deterrents that hinder
providing the best quality care in a timely manner to our veteran
patients along with recommendations to remove or alleviate those
deterrents?

**Answers**:

1.  I feel there are too many pharmacy restrictions for medications ...
    Why should a patient have to wait for an appointment with mental
    health for sleeping medication? Why does a patient have to see a
    cardiologist to receive plavix? I suggest that the primary care
    provider at least should be able to give the initial prescription
    while the patient is waiting for his appointment. Another suggestion
    is to have a template for the medication like we have for viagra and
    the cox-2 inhibitors.

2.  One challenge is thinking about managing our demand differently from
    the traditional way in which we separate care into urgent and
    routine. The principles associated with ACA when implemented enable
    us to not only improve access, but also improve efficiency, decrease
    cost, improve satisfaction and improve quality. There is much yet to
    be done to change our traditional way of delivering care in the
    outpatient setting and cementing it is not our culture. There is
    much to be gained.

3.  Communication of results to patients. Lack of Office Manager staff
    to manage a large Primary Care Clinic. We need to start streamlining
    what our providers do and let them spend more time with the patients
    and less time on paper.

4.  The scheduling package is a great deterrent. A commercial package
    that interfaces with VISTA would be helpful in making the
    appointment process more modern to address the needs for flexibility
    without losing the patient in the process.

5.  How to best provide clinical and administrative support for the
    providers to be their most productive. The mix of staff to support
    PC is very diverse across the nation. Best practices should be
    explored and staffing patterns that include a patient acuity system
    should be explored. There was a VA doing this, but it has fizzled
    out.

6.  Lack of money and a continued emphasis on a hospital based system.

7.  As part of IHI initiative we have addressed the primary care wait
    times in most of our clinics. I would like to see this aggressively
    pursued in subspecialty clinics as well. Long waits in certain
    subspecialty clinics such as GI, Derm, Ortho clinics remain a
    significant barrier to delivery of timely and comprehensive care for
    our patients. Limited subspecialty access calls for innovative
    approaches to train and develop mid levels or internists with
    subspecialty interests to collaborate and deliver some of this care.
    Scope of utilizing telemedicine at our remote sites to deliver
    subspecialty care remains to be further explored.

8.  I would also like to formulate a strategy to address growing demand
    for primary care services in light of very limited resources. It
    would be nice to analyze how resource allocation for Primary care is
    taking place and if a planning tool could be developed for such
    purposes for broad application.

9.  Lack of adequate support staffing remains a problem in many of our
    primary care and subspecialty clinics. Even though we have
    established standards, they are not met in many instances. Improving
    clinic efficiencies through improving support staffing and patient
    flow also remain an area that could be improved upon.

10. The main hindrances involve waits times in specialty clinics,
    radiology to get MRI/CAT scans done, wait times in elective and
    urgent but not emergent operations.

11. A prime example is the time it takes to work up malignancies within
    our system. Even with case managers shepherding patients through the
    process\...it takes a week or two to get someone into pulmonary
    clinic then another 2 weeks to get the bronch then 2 weeks for the
    ct scans, then two weeks for the ct guided biopsy, two weeks to see
    ct surgery, two weeks for mediastinoscopy then another month for the
    resective surgery. I count 12-13 weeks at BEST.

12. Part of our problem is that many specialties only meet 1 time per
    week (sometimes 1 session q 2 weeks).

13. Many of our surgical specialists are only part time committed to the
    VA (pay and volume are issues embedded in this).

14. The lack of specialty clinic support staff\--primary care has done a
    better job of building efficient systems of care delivery.

15. Lack of a single physician leader for the outpatient specialty
    clinics\--vocal advocating voice.

# Lack of radiologists due to pay scale issues.

16. The first front line contacts with our veteran patients are often
    clinic clerks. Those positions are high turnover positions because
    of low pay and no incentives to stay in the position. Clinic clerks
    are a valuable resource that can positively impact both patient and
    provider satisfaction. It would be beneficial to create a means to
    improve pay and educational requirements for those front line
    positions.

17. Lack of cutting edge technology at times. all endoscopic ultrasound
    has to be fee based to Yale due to lack of this technology here
    (same with laser Rx for diabetic retinopathy).

18. Would like to see development programs for junior faculty to keep
    them here and keep them interested/engaged. Development programs for
    mid-levels that get burnt out doing high stress/high complexity
    work. Competitive salaries for mid-levels that do primary care
    similar to nurse anesthetists.

19. Development programs for nursing in outpatient ambulatory
    care\--triage assessment, nursing care of the cardiovascular
    patient, wound care, etc.

20. Lack of leadership commitment and staff knowledge and skills in
    clinical system improvement.

-   Build awareness and skills for improving primary care clinical
    Microsystems.

-   Foster improvement collaboratives to accelerate clinical improvement
    and promote learning and sharing across the VA.

-   Some limitation on copying and pasting, or at least some way to
    identify what text has been transferred into a note. This has
    medico-legal implications, and, in some instances, is a significant
    deterrent to patient care, particularly for consultants, PAs, ARNPs
    or peer reviewers who must wade through the charts trying to decide
    what is germane to a specific visit. Numerous suggestions have been
    made, including book-marking individual items in the chart for
    copying and pasting or using a different colored font for pasted
    material to distinguish from the visit note, none acted upon. I do
    think that limited copying and pasting is critical to the survival
    of Primary Care Physicians who are, at least in VISN 8 swamped by
    the continuing growth of requirements (which is made worse by the
    VERA lag, and the yearly caps on increases in budget).

-   One of the drawbacks in the past to management and patient care in
    the non-VAMC outpatient clinics that are remote to the VAMC, and
    that in NF/SG provide 2/3 of the Primary Care services, is the
    tendency of the leadership, usually located in a VAMC, to make
    decisions without the input of the remote clinics. This pattern of
    decision usually leads to dysfunction and both angst and
    unhappiness.

-   Deterrents that hinder providing the best quality of care in a
    timely manner are variable and can depend on many factors. I believe
    that most everyone comes to work wanting to do they best job they
    can. However, systems issues and staff not having access to the
    right tools may cause delays. I believe that systems can be
    streamlined through establishing minimum standards and processes
    that allow some modification by local Medical Centers & VISNs in
    order to meet specific outcomes.

21. Teaching the veteran about his illness, upcoming procedures,
    surgery's , medications effects. Too many veterans walk out the door
    not knowing the next step in their care and what can they do to
    maintain better health. Providers are pushed to see more patients
    and with the responsibilities of computerized entry has required the
    provider to do more clerical type work. Solutions: Time to study the
    flow of patients and what each team member is currently doing and
    what can be done to improve customer service. Increase telemedicine
    appointment instead of veteran needing to travel long distances.

22. Clinic cancellations, support staff clinical staff doing
    non-clinical jobs.

**Medical/Surgery Initiatives**

**Question 3. :** What do you think or would want the Medical/Surgery
Services in VACO to pursue as major initiatives?

## Answers:

1.  Diet and Exercise education for prevention of prevalent diseases
    like diabetes and heart disease.

2.  I would like to see them continue to support the work on ACA
    implementation and spread.

3.  Improving patient satisfaction, efficiency of ordering tests and
    discharging patients on the inpatient service.

4.  Shift the focus of Quality review to Specialist Services.

5.  Office Manager positions to help with the day to day running of the
    PCC clinic

6.  Better ways to seek advice on specialty care concerns.

7.  I would like Med/Surgery to be a true linkage from inpatient to
    outpatient care. We continue to be fragmented and separate in our
    goals and treatment plans.

8.  Two areas of focus should be the lack of specialty care beds and the
    long waits for elective surgery.

9.  Improving outpatient access to subspecialty care needs attention.
    Most Medicine and Surgery

> Chiefs have their attention primarily focused on inpatient care and
> medical education and research.
>
> Establishing standards for productivity for sub specialists remains
> relatively unexplored.

10. Major initiatives-competitive salaries so we could recruit the best
    and the brightest in specialties/ surgery.

11. Build leadership and action for clinical micro-system improvement in
    ambulatory care, using a balanced set of measures (access, clinical
    performance, patient satisfaction, staff satisfaction, efficiency).

12. Develop, test and implement a model of regionalized, integrated Eye
    Care.

13. In collaboration with VA ACA Steering Committee, improve access to
    care using the ACA Ten Key Changes.

14. The absence of a standardized way in which a Primary Care Provider
    can speak with a Specialist to ascertain whether the patient problem
    with which he/she is considering for referral is something that can
    be dealt with over the telephone, or V-tel, rather than sending the
    patient for a face-to-face visit. In addition, some of the
    consultation requirements are clearly built to protect the specialty
    service from considering the patient, and this is one of the
    difficulties with these contracts when Primary Care Providers are
    not involved intimately in their development.

> i\. Access and prevention of complications related to chronic
> diseases. I would like to see the continued pursuit to monitor the
> provider\'s role in Health care.

ii\. Information Services. To include the time

> spent in completing encounters, coding, progress notes and non-direct
> patient care administrative matters. In addition, the enhancement of
> Surgical Services provided to veterans at the facility level verses
> downtown consults in an attempt to provide a better service at less
> cost.
>
> iii\. Another area that continues to be addressed at the facility
> level is the clarification of the co-managed care policy and the
> availability of medications to NSC and SC veterans a like. We should
> continue to identify, review and process data enhance available
> medicine and specialty care services to our veterans.
>
> iv\. Improve clinical care through innovative methods, such as group
> visits.
>
> v\. Expanded use of technology (i.e., telemedicine and tele-home
> care).
>
> vi\. Improve care coordination for veterans being seen by community
> providers and VA providers.

####### 15. Succession Planning Telemedicine and Tele-home care

> Partner with other VA's in or across VISN's to do more telemedicine
> clinics. Look at several VA's working together to hire a scarce
> medical such as Dermatology or Cardiology. Implement more group
> clinics.

####### Truly be a patient centered organization.

![](media/image2.wmf){width="1.6375in" height="0.9069444444444444in"}

**P*rimary* C*are***

***welcomes Dr. Gerald Cross***

The Medical/Surgical Services Office is pleased to announce the
appointment of Dr. Gerald M. Cross as the National Director for Primary
Care. Dr. Cross graduated from Loma Linda University Medical School. He
has completed Residency and two Fellowships. He is Board Certified in
Family Medicine.

Dr. Cross has extensive experience in primary care, managed care, Joint
Commission compliance, risk management, employee training, and strategic
planning. He has been in DoD leadership positions serving in command at
four facilities. In addition, he was deputy commander of the European
region. Dr. Cross also has been very involved with health care
education. He was responsible for training programs including Internal
Medicine, Family Medicine, Emergency Medicine, OB/GYN, Physician
Assistants, Nurse Anesthetists. He has supervised health care providers
from LPNs to Neurosurgeons.

Dr. Cross has served on many national committees. He served as a
Consultant to the Surgeon General and served either as a member or
leader of committees for diverse organizations including the American
Academy of Family Physicians and the Food and Drug Administration. He
has been called upon to brief senators, representatives and
congressional staff.

He has educated audiences in both the United States and overseas on
topics of health promotion, quality assurance, and substance abuse
prevention. Please join us in welcoming Dr. Cross! He may be reached
through the Global Address Book or at 202-273-8558.

***Improving the Quality of Care Through Improving Colorectal Cancer
Screening Compliance in an Ambulatory Care Clinic***

***March 15, 2004***

*A Fellow Project Prepared for the Credentials Committee In partial
fulfillment of the Requirements for Fellow Status In the College of
Healthcare Executives*

*By: Brent A. Armstrong M.D., M.S.H.A., F.A.C.P., C.H.E.*

*ACHE# 716884*

*Chief of Ambulatory Care*

*Department of Veterans Affairs*

*Amarillo VA Health Care System*

*6010 Amarillo Blvd. West*

*Amarillo, TX 79106*

"Improving the Quality of Care Through Improving Colorectal Cancer
Screening Compliance in an Ambulatory Care Clinic".

Organizational Information:

The organization discussed in this case report is a Healthcare System,
established in 1939, which offers general medical and surgical inpatient
care, day surgery, extended nursing home care, primary and specialty
care, mental health services and substance abuse treatment to a
population of 75, 000 veterans in Texas, New Mexico, Oklahoma, Colorado
and Kansas. The center of the service area is a small city of 175, 000
with a technological and agricultural economic base. The areas
surrounding the satellite clinics (CBOCs) are mainly agricultural, with
many of these areas designated as medically underserved. The
organization has transitioned from a stand-alone hospital and satellite
outpatient clinic to a multi-facility health care system through the
placement of community based outpatient clinics (CBOCs) in medically
underserved areas. The organization discussed is part of the Department
of Veterans Affairs and subsequently operates in a political environment
subject to the Congressional budget cycle, national priorities and
changes in administration. This environment routinely affects short and
long-term planning, budgeting, and staffing in the organization since
the Congressional budget cycles are only one year and planning for
service changes and capital investment often span 2 years or more
(Source #1).

Brief Summary of the Problem and Role of the Author:

This case report looks at how we improved the quality of care we
delivered to our patients through improving our compliance with
colorectal cancer screening. By using a performance improvement model
for colorectal cancer screening we were able to significantly improve
the quality of care delivered to our patients. The author, the Chief of
Ambulatory Care, worked with nursing, physician, mid-level providers,
and the performance improvement and medical media departments to put
into place a performance improvement model which improved the screening
of our patients for colorectal cancer from a compliance score of 37% in
December 2002 to a compliance score of 74% in December 2003.

Description of the Problem:

Colorectal cancer is the 2nd leading cause of cancer death in the Untied
States. The VA Healthcare system, like other healthcare systems has been
attempting to appropriately screen patients for colorectal cancer. In
December of 2002 our compliance score for colorectal cancer screening
was 37%. During the latter half of the decade, specific monitors
"performance measures "were developed to quantify effectiveness of
primary care screening. First, external reviewers were invited into
every VA facility to audit medical records for performance on a wide
variety of chronic disease and prevention performance measures.

This program, known as the External Peer Review Program (EPRP) tabulates
performance measures selected by VA leadership as being important
parameters to evaluate quality of care for the primary care provider and
team. Medical charts are manually audited monthly at our facility by the
EPRP reviewers, allowing an estimate of facility performance for most
measures, such as colorectal cancer screening. The measurement data for
the performance measures can be found on the VA's Office of Quality and
Performance website (Source #4). Benchmarks have been established for
each of these performance measures, such as colorectal cancer screening.
The goal is set at 72% for a fully satisfactory score and 75% for an
exceptional score for colorectal cancer screening (Source #3). The VA
Healthcare system is graded at the level of the director, the Chief of
Staff and the service level, in this case the Chief of Ambulatory Care,
on the quality of preventative care for our veteran enrollees. As of
December 2002 we were falling short of this mark for colorectal cancer
screening at our facility.

The aim of this project was to design and implement a performance
improvement model to increase the EPRP compliance scores for colorectal
cancer screening in the Ambulatory Care clinic in order to improve the
quality of care delivered to our veterans. Clinicians can use data to
improve daily clinical practice (Source #2).

Administrative Decisions and Results:

Through use of a performance improvement model the Ambulatory Care
clinic was able to improve the compliance scores for colorectal cancer
screening in the Ambulatory Care clinic as can be seen in the graph
below:

**Plan:**

The first step was to increase the awareness of the patients, nurses,
providers and mid-level providers of the importance of colorectal cancer
screening. The next step was to screen the patients and capture the
screening done into the computerized patient record system, thus
documenting that the screening for colorectal cancer had been done.

**Do:**

![](media/image3.wmf){width="5.992361111111111in"
height="4.104166666666667in"} Medical media assisted in creation of both
a poster (Appendix A) and a patient education pamphlet for colorectal
cancer screening. The use of a clinical reminder, based on accepted
clinical practice guidelines and EPRP performance measure criteria, was
mandated in order to document in the computerized patient record system
(CPRS) that the patient had been screened appropriately for colorectal
cancer, thus employing a method to document the compliance (Appendix B).
Nurses, physicians and midlevel providers were then educated about the
importance of colorectal cancer screening in staff meetings. The staff
was also instructed that appropriate screening for colorectal cancer
included either stool cards (done yearly) or screening flexible
sigmoidoscopy (done every 5 years) or screening colonoscopy (done every
10 years). The posters and patient education pamphlets were placed in
all the clinical areas in the Ambulatory Care clinic used by nurses,
physicians and midlevel providers.

The nurses were instructed to emphasize the importance of colorectal
cancer screening to the patients and how to instruct the patient on
collection of fecal occult blood testing (FOBT) specimens for testing.
The physicians and mid-level providers were instructed how to use the
clinical reminder in the CPRS to document that either they or the nurse
had given the patient stool cards or had ordered a screening flexible
sigmoidoscopy or screening colonoscopy. The plan was then put into
action.

**Check:**

EPRP reviewers audit the patients\' medical records monthly in order to
ensure that performance measures such as colorectal cancer screening are
being done. Monthly compliance scores of colorectal cancer screening
were shared at the Ambulatory Care staff meeting with all staff. The
CPRS ADPAC to created a clinical reminders due report for the colorectal
cancer screening clinical reminder. The clinical reminders due report
drills down to the level of the provider and can demonstrate by
percentage the colorectal cancer screening clinical reminders completed
by each provider (Appendix C).

**Act:**

Review of the EPRP data showed that for the colorectal cancer screening
performance measure compliance with the above performance improvement
model showed scores that averaged around 50%. Discussion with nurses and
providers showed that stool cards (FOBT) cards were not being returned.
Further partnering with nursing service led to the development of a
system whereby the nurse would continue to emphasize the importance of
colorectal cancer screening to the patient and give the patient a packet
of FOBT cards which contained patient instructions and had the proper
postage on the cards. The nurse also began to phone the patient if the
stool cards were not returned within a 2-week period. The follow-up
phone calls by the nursing staff, combined with the other steps in the
performance improvement model increased our compliance rate with
colorectal cancer screening to 74% as of December 2003. Additionally at
the same time the medicine department started a flexible sigmoidoscopy
and colonoscopy education class and increased their capacity to do
flexible sigmoidoscopies to help increase the capacity of their services
in colorectal cancer screening.

In summary, utilizing a performance improvement model and listening to
feedback from the front line staff in the Ambulatory Care clinic we were
able to increase our compliance rate with colorectal cancer screening
from 37% in December 2002 to 74% in December 2003. Performance measures
such as colorectal cancer screening are important because central VA
leadership expects fully satisfactory ratings from the regional
networks, which are composed of VA facilities like ours, and require
explanations and action plans from networks not achieving their
performance goals. For sub-optimal performance ratings related to
primary care, facility leadership would task primary care leadership to
implement action plans at the clinic level to improve quality of care.

Source Materials:

1.  Amarillo VA Health Care System Organizational Profile

2.  Nelson, E. "Building Measurement and Data Collection into Medical
    Practice" *Annals of Internal Medicine* 1998;128:460-466.

3.  FY2004 VHA Performance Measures Technical Manual.

4.  [http://vaww.oqp.med.va.gov](http://vaww.oqp.med.va.gov/)

Appendix A: Colorectal Cancer Screening Poster

![](media/image4.wmf){width="4.960416666666666in"
height="7.513888888888889in"}

Appendix B: Colorectal Cancer Screening Clinical Reminder in CPRS

![](media/image5.wmf){width="6.020833333333333in"
height="4.5159722222222225in"}

Appendix C: Clinical Reminder Due Report For Colorectal Cancer Clinical
Reminder

![](media/image6.wmf){width="7.125in" height="3.972916666666667in"}

######### TONI LAWRIE HONORED

######### *Authors: Sara McVicker, Joan Furey, Peggy Mikelonis, and Carol O\'Brien*

Mary A. (Toni) Lawrie, now retired, was the Women Veterans Program
Manager at Bay Pines VAMC and Lead Women Veterans Coordinator for VISN
8, was recently honored for her many years of service to veterans.

On January 16, 2004 Ms. Lawrie was informed that the Women Veterans
Clinic at Bay Pines would be named "The Mary A. Lawrie Clinic for
Women". Joy Easterly, ACOS/Patient Care Services, Ms. Lawrie's immediate
supervisor, was instrumental in gaining approval for the naming of the
clinic. Ms. Easterly, Carol O'Brien, PhD, the Psychologist in the
Women's Clinic and Peggy Mikelonis, Women Veterans Program Manager at
the Tampa VAMC, presented her the engraved plaque that will be placed at
clinic entrance. The official naming ceremony and ribbon cutting will be
held after Ms. Lawrie recuperates from major surgery.

On January 21, 2004 Ms. Lawrie received The Secretary's Commendation,
which read:

*In recognition of your pioneering efforts, professional leadership, and
selfless dedication in advancing the provision and delivery of health
care and benefits to women veterans. Your commitment, integrity and
compassion for veterans have ensured that the Department of Veterans
Affairs successfully carried out its mission: To provide the highest
quality care to the men and women of the United States who served in
defense of our freedoms. You have discharged this trust and
responsibility in a manner that has brought exceptional credit to
yourself, the Department and the United States Government.*

Before joining VA, Ms. Lawie served two years in the Peace Corps with
assignment in Malaysia. She then joined the US Air Force and served at
the 12^th^ Air Force Hospital in Cam Ranh Bay, Republic of Vietnam from
1968-1969 and at Keesler AFB, Biloxi, MS from 1969-1970. She arrived at
Keesler from her assignment in Vietnam just in time for Hurricane
Camille. She joined VA in 1981 as Head Nurse in the Nursing Home Care
Unit and was promoted to Associate Chief Nurse for Ambulatory Care in
1983. While at Bay Pines, she served for many years as the planner and
coordinator for the annual hurricane drill because of her experience
with Camille.

In 1987 Ms Lawrie accepted the collateral duty of Women Veterans
Coordinator (WVC) at Bay Pines, and assumed the position full-time in
1993. During her early years as WVC, she began the Well Women's Clinic
at Bay Pines, a pilot program offered only on Saturday mornings, where
women could receive preventive health care such as breast exams, pap
smears, and gender specific health counseling. In the ensuing years,
under her direction and guidance, this half day Saturday clinic evolved
into a comprehensive women's clinic serving over 3500 women. The clinic
now operates 5 days a week in dedicated space providing Primary Care,
Breast Care, Well Women's Services, Gynecology, Nutrition, Social Work,
Psychological, and Psychiatric services. In collaboration with Carol
O'Brien, PhD, the Psychologist in the Women's Clinic, Ms. Lawrie
pioneered the Sexual Trauma Treatment program at Bay Pines, which was
selected as a gold award winner of the 2001 Wyeth-Ayerst HERA Award for
improvement in women's health outcomes.

Ms. Lawrie and her colleague, Peggy Mikelonis, ARNP, Women Veterans
Program Manager (WVPM), Tampa, established the women veterans' program
manager mini-residency. The mini-residency was developed to assist newly
appointed WVPMs in assessing and developing women's programs and
services at their facilities. Since its inception in 1995, the week-long
program has afforded over 100 new WVMPs, Vet Center Counselors, and
personnel from Veterans Benefits Administration the opportunity to gain
an understanding of the scope of the WVPM role and inspired them to meet
the challenges of the position. As of the fall of 2003, 73 of the
trainees remained in their positions. The National Women Veterans Health
Program is now replicating parts of this training program across the
country in order to continue this innovative program that Ms. Lawrie and
Ms. Mikelonis have so successfully presented for over 8 years. The last
mini-residency program was held at Tampa/Bay Pines September 22-28,
2004.

In 2001, Ms. Lawrie received the Women Veterans Coordinator of the New
Millennium Award for her multiple contributions and her creative and
innovative approaches to providing services to women veterans.

Ms. Lawrie is highly regarded by her co-workers and colleagues as both a
skilled provider and committed mentor. We wish her a speedy recovery
from her surgery and happiness in her retirement.

######### *[2004 CONFERENCE CALL SCHEDULES]{.underline}*

######### *Dial in number is 800-767-1750*

######### [Medical-Surgical Service Conference Calls:]{.underline} are held every other Monday @ 1:30 p.m. ET. ACCESS CODE: 18523 Dates are announced. (May 10, 24, June 7, 21, July 5, 19,)

######### [Field Advisory Committee Chair Conference Calls:]{.underline} are held every third Tuesday of each month @ 3:00 p.m. ET. ACCESS CODE: 39186

######### 

+-----------------------+-----------------------+-----------------------+
| ######### April 20    | ######### July 20     | ######### October 19  |
+-----------------------+-----------------------+-----------------------+
| **May 18**            | **August 16**         | **November 16**       |
+-----------------------+-----------------------+-----------------------+
| **June 15**           | **September 21**      | **December 21**       |
+-----------------------+-----------------------+-----------------------+

######### [Primary Care Conference Calls]{.underline}: are held every third Wednesday @ 1 p.m. ET.

######### ACCESS CODE: 28097

## Schedule for M-S News Articles

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  FLOW               **3rd                     **4th                      **1^st^          
                     Q/2004**                  Q/2004**                   Q/2005**         

                     April      May     June   July       August   Sept   Oct        Nov   Dec

  Articles Submitted            8              15                         27               

  Distribute to                 29                        5                          17    
  Board Members                                                                            

  Comments to PC                        10                23                               1

  Final Presentation                    17                         17                      8

  Electronic & Hard                     30                         24                      15
  Copy Distribution                                                                        
  ------------------ ---------- ------- ------ ---------- -------- ------ ---------- ----- --------

*Thank you to the MAP editorial board members who served, some, for
several years: Dr. Arnold Gass, Rebecca Goldsmith, PA-C ,Dr. Wendel
Jones, Dr. Lois Katz, Rivkah Lindenfeld, PhD, Andrea Van Horn, CNP,
Windy Kennedy HHS.*

*Medical/Surgical Services websites:*

[*http://www.va.gov/kidney*](http://www.va.gov/kidney)

[*http://vaww.va.gov/primary*](http://vaww.va.gov/primary)

*<http://www.health.gov/nhic/pubs/><http://www.va.gov/diabetes>*

[*http://www.va.gov/cancer*](http://www.va.gov/cancer)

[Resident Supervision VHA Handbook 1400.1]{.underline}

Mary Stout, Chief, VHA Forms, Publications and Records Management
announced that the

Resident Supervision VHA Handbook 1400.1 has been approved for
distribution. It is

available on the following websites:

<http://www.va.gov/pub/direc/health/>

<http://vaww.va.gov/pub/direc/health>/