October 2, 1995

Deputy Under Secretary for Health

Transition Work Group Reports - Catalog of Comments and Recommendations

All VA Staff

1.  In late July and early August, 1995, six work group reports which set forth ideas and recommendations for implementing Dr. Kizer's Vision for Change were made available for review by all interested staff throughout the field and in headquarters.  Numerous comments to these reports were received and cataloged by recommendation for each work group report.  In some instances the comments received precipitated revisions to the work group's original recommendations.

2.  The attached summary document is one of six catalogs of recommendations.  The recommendations were extracted from the work group report.  The catalog includes each original recommendation followed by a summary of the comments received, the work group's reaction to the comments, the rationale for that reaction, and any resulting change to the recommendation.  In some cases, the "comments" section is followed by "approve" or "disapprove."  This is an indication of the work group's reaction to the comments.  It does not indicate a final decision by the Under Secretary.

3.  Please keep in mind as you review these documents that they catalog recommendations of the work groups to Dr. Kizer.  Dr. Kizer is in the process of reviewing the recommendations for final decision and implementation.

4.  It is also important to remember that the restructuring of VHA will evolve over time.  While some changes began on October 1st, many things that need to happen are sequenced in time beyond that date.  This is the reason the July reports did not describe the complete closure on many issues that some reviewers may have expected.  The six work group reports are being summarized and edited to create a new document, Vision for Change - Implementation, which should be distributed in November 1995.  This will be a companion report to the original Vision for Change that was published in March 1995.

5.  Please direct any questions about these documents to Greg Neuner in Headquarters at 202-273-5823.




Thomas L. Garthwaite, M.D.

Attachments

VISN ACTIVATION WORK GROUP
EXECUTIVE SUMMARY OF COMMENTS RECEIVED
IN RESPONSE TO DRAFT REPORT


Over 140 individuals responded to the report of the VISN Activation Work Group.  In general, comments were highly positive with many specific references to the qualify and comprehensives of work and the strength of the approaches suggested.  All comments were carefully reviewed and were captured in one of two ways.  Those referring to specific recommendations were matched with the recommendation and are included in this document.   Those of a general nature were categorized in terms of key thoughts expressed and attached in another document (e\visn\nonrec.doc).  Each comment was reviewed and rationale for agreement or disagreement with the comment was developed.  This Executive Summary will highlight the tone and general themes of the responses.

A number of respondents felt the level of detail in some sections of the document was too great, inhibiting flexibility in the new organizational structure.  The need for flexibility and autonomy at the VISN level in order to achieve the mission intended was stressed.  Others believed that there was not enough detail to fully communicate where certain existing functions would be placed.  Skepticism was expressed regarding the level of autonomy which would actually be delegated and several comments that the report appeared inconsistent in this regard (e.g., VISN Directors have delegated authority for operations yet the size of their staff was limited to 7-10 persons, the staffing plan would need to be submitted for approval, etc.).

One area which obviously needs more elaboration in the reports of both the VISN Activation Work Group and the Headquarters Restructuring Group is that of the role of "special programs" in the proposed reorganization.  It certainly has always been the intent that special programs would be maintained and even strengthened under the new structure.  Several comments from service organizations indicate that this intent may not be as clear as it should be.

Many comments were received relating to the role and composition of the VISN Executive Leadership and Management Assistance Councils.  The manner in which the two groups would function appeared to be unclear in terms of their advisory vs. "operational" relationship.  Specific recommendations were made as to the inclusion of certain individuals and/or groups on the councils.

Proposed staffing within the VISN office generated a number of responses.  The limitation of 7-10 staff for the VISN Office was seen as unnecessarily restrictive and perhaps inadequate.  A number of comments specifically recommended the addition of certain types of staff (i.e., clerical, nursing, social work, etc.)  In particular there were many comments regarding the need to have a strong nursing presence within the VISN.  The recruitment of Clinical Services and Financial Managers before it was known where the VISN Office would be located and who the VISN Director would be was not perceived positively.  There was general concern that in the attempt  to expedite VISN start-up through early recruitment, the applicant pool, quality of applicants and achievement of well functioning "teams" would be sacrificed.

The overall pace of the VISN transition, dissolution of regions and restructuring of Headquarters was viewed by many as exceedingly rapid.  Concern was specifically expressed relating to the fact that so much change would be occurring simultaneously without time to deal with the "people" issues required to create such massive cultural reorientation.

The differences in approach between the recommendation of the VISN Activation Work Group and the Headquarters Restructuring Work Group relating to VISN Support Teams was noted by many.  The contrast between the 11 member team recommended by VISN Activation and the 42+ members of the teams proposed by the Headquarters Restructuring Work Group is significant.  Comments ranged from the belief that the support team proposed by the VISN Activation Work Group was "vital to the success of the implementation"  to the team would provide yet another level of bureaucracy.  There was also concern that current functions perceived to be redundant and unnecessary would be perpetuated in the VSSCs and Operations.  One comment was that the talents and skills of clinicians on the team would be underutilized in what was perceived as an "administrative" role.  Also the issue of salary inequity for individuals working on the support team was acknowledged.

The VSSC has been one of the most heavily debated issues in this process.  Originally, the SSC emerged as a concept to deal with issues outside of Headquarters, but in a forum larger than the VISN.  At that time, the VSSC seemed a reasonable piece of the organization to deal with roll-up functions for finance and construction, larger planning issues and perhaps as a "home" for any region functions which did not neatly fit into other parts of the organization.  As the planning process began and the debate ensued, the need for this function, in view of current computer capabilities, the organization and structure analysis that occurred during the planning process, etc., became less clear and it appeared there might be a time-limited need for the VSSC--to absorb region functions that would gradually be transitioned to VISNs and Headquarters during initial implementation.  Current thinking of the Work Group is that establishment of the VSSC would be redundant, that we should not establish something which we would then phase out in the next six to twelve months.  Hence the recommendation that VSSCs should be established only if a value-added need is determined through analysis of Region functions which the VISNs and CNO office will now be conducting.  This analysis is an important task and must be accomplished without bias.  Many comments support the Work Group's conclusion that the VSSC is redundant.  This proposed change to the role of VSSCs outlined in the Vision for Change should be carefully considered, and probably adopted, but no final decision should be made until the analysis occurs. 

Several comments were received from the General Counsel relating to some of the procedural matters which should be considered in various parts of the implementation (i.e., leasing, legislative changes, etc.).  These comments will be useful as implementation planning proceeds.            

Suggestions were made relating to the proposed outplacement program and difficulty which may be encountered in outplacing region staff.  The plan for reassigning remaining region staff to the office of the CNO on October 1 and conducting a thorough review of current region functions drew many comments relating to the need to be "people- sensitive" during the transition. Also many of the respondents wanted more detail regarding exactly where current region functions would be placed and who would hold responsibility for them.  There were specific recommendations regarding which functions were no longer needed, which programs should remain and where they should be placed.  

Comments related to affiliations were diverse, ranging from recommending immediate decentralization of education funding and house staff positions to advising that they remain centralized.  The one theme which came through in the comments was agreement that further study would be required and that there should not be a rush to implement change in this area in light of the many other structural and cultural changes which would be undertaken simultaneously.

In summary, while there were not major issues addressed which had not been contemplated and discussed by the Work Group in its deliberations, the comments were quite helpful.  They will be useful as further implementation strategies are developed and recommendations are refined.  The level and thoughtfulness of many responses was indicative that the "field" is indeed engaged in the process.


Recommendation:
2.1 VISN Directors with concurrence of the CNO will determine the organizational structure that best meet the needs of their respective VISN; will support the operation of a fully integrated managed care organization and support the following major functions:  leadership, planning, resource management, clinical services management, human resources management, performance measurement, management of affiliations and internal and external stakeholders relations.

Action Required:
2.1.1 determine organizational structure

Action Office: VISN Directors

Target Date: 11/15/95

Comments: We received four comments on the flexibility of VISN Directors to develop the VISNs.  Most were supportive of the idea  -- "We believe that flexibility is the key to success.  It is hoped that unneeded services and functions will be eliminated."

Approve

Rationale: We are attempting to maintain as many degrees of freedom as possible.  Maximum flexibility will be allowed.

Comments: However, one comment disagreed -- "This is the same as 'no recommendation.'  Specific programmatic requirements can be identified, they are currently being performed by Regional Offices.  They should be stated in the Report and specific plans for their continuation or elimination proposed."

Disapprove

Rationale: The specific guidance on how to best perform existing regional functions will be forthcoming following the detailed review suggested during the transition process.

Comments: One other comment was concerned with the concurrence of the CNO for VISN organizational structure  -- "This appears to be contrary to the concept of decentralization of responsibility and accountability."

Disapprove

Rationale: The emerging structure of the VISN (particularly during VISN activation) is such that it requires close integration and coordination between VISNs and Headquarters to insure all essential issues are considered when assigning limited numbers of FTE.  The intent is not to be restrictive but to assure that discussions occur.

Comments: Three comments were concerned with the staff levels within the VISN office.  "Given the initial functions assigned to the VISNs and the likelihood of assuming other functions, a major concerns whether or not there will be sufficient staffing to accomplish the tasks assigned."

Approve

Rationale: The recommended 7-10 FTE is for the VISN office itself.  All FTE in all VISN facilities can be utilized to undertake the work of the VISN.

Comments: "Some analytical resources currently at individual facilities may have to be pooled at the VISN level while maintaining adequate resources at the local facility.  The use of task forces and councils is essential in streamlining the VISN and VSSC."

Approve

Rationale: The need to tap the resources of the VISN is basic to the new organization.

Comments: "Although the report offers a great deal of detail regarding certain aspects of the transition from the Region structure to the VISN organization, adequate information is not available regarding the means by which the VISN Directors will implement the changes necessary to bring the VA into the realm of competition with the private sector.  Historically, the VA has been restricted by many issues which impact its operations; without elimination of these restrictions it is uncertain whether the VISN organization can effect necessary changes."

Rationale: The need to eliminate unnecessary restrictions is recognized.  Attempts will be made to reduce them.  The "means" by which a VISN Director will implement change is not prescribed in order to offer maximum flexibility.

Comments: Another comment stated, "..that while the VISN Director appears to have authority to change modify or delete functions at facilities in his/her area, it's not clear what authority he/she has in reassigning personnel.  Specifically he/she appear to be prohibited from assigning employees, surplused by increased efficiency to the VISN office if the FTE of 10 - 12 is exceeded.  For example, with the resource allocation for the entire VISN resting with the CFO (and CEO) he/she cannot accomplish this alone; nor can it be done efficiently and effectively by a "committee or advisory group" (the members of which are certain to have parochial interests).  He/She will need a staff working for and with him.  That is not to suggest that the fiscal operation at any facility should be abolished but rather to recommend that fiscal staff working on VISN fiscal responsibilities be assigned to the VISN.  This is but one example of the probable need for personnel realignment within the VISN."

Approve

Comments: "One of the stated goals of the VISN structure is the inclusion of external health care providers as part of the network.  However, the VISN reports do not address the process for developing, writing, negotiating, and signing these contracts or who within the VISN has the expertise and authority to complete contracts with external providers."

Approve

Rationale: The intent is to give VISNs full authority to develop needed contractual relationships.

Comments: One comment agreed that VISN management will need to take advantage of research (HSR&D, Affiliates, VHA Research Service).

Approve

Comments: One comment suggested that we add research as a VISN Director responsibility that states, "VISN Directors should encourage research, promote its application to ensure best practices, and publicize its benefits to veteran patients."

Approve

Rationale: There is presently a separate study of research activities and needs.  However, VISN Directors' performance contract will include language specific to maintain and enhance the research mission.

Comments: "VISN clinical advisory councils such as Mental Health and Long Term Care could strengthen and support efforts, especially if an interdisciplinary membership model is used to share the broadest appropriate knowledge base to address issues and problems facing clinical programs in the VISN."

Approve

Rationale: 

Comments: These will be developed as the VISNs mature.  VISN Directors may establish whatever advisory councils deemed necessary to assist in VISN management and operations.

Approve

Proposed Revision: No change recommended at this time to the recommendation.

Recommendation:
2.2 Each VISN Director will establish an Executive Leadership Council consisting primarily of internal stakeholders and a Management Assistance Council consisting primarily of external stakeholders.  These councils will represent diverse viewpoints and serve to advise the VISN Director regarding key aspects of VISN operations.

Action Required:
2.2.1 establish Executive Leadership Council

Action Office: VISN Directors

Target Date: 10/15/95

Action Required:
2.2.2 establish Management Assistance Council

Action Office: VISN Directors

Target Date: 10/15/95

Comments: There were seventeen (17) comments related to the ELC and the MAC.  Most comments support both councils.  The following comments and questions relate to establishment of these councils--

"How will the members of the councils be selected?  What will be taken into consideration?  Can advisory councils, as outlined, function efficiently in a decremental budgeting environment?"

"VISN use of advisory/management councils to resolve local issues -- How would these groups relate to national policy and national advisory groups?  (What are the limits of 'local' issues and 'loca' authority?)"

Rationale: The details of Council membership and organization will be determined as the organization develops based upon individual VISN needs.  Advisory councils can be very helpful and supportive even in a "decremental budgeting" environment.
Linkage is through VISN Directors and CNO.  Limits of authority determined by USH and CNO.

Comments: We received several suggestions for membership to the Executive Leadership Council (ELC).  This included such professions as nurses ("The nurse's broad perspective of the continuum of patient care and support of seamless delivery of systems makes him/her an ideal candidate for inclusion.") and mental health representatives ("...to reflect the importance of mental health in the composition of VHA health services.").  Other council suggestions included: "Membership should include all the Directors within each VISN initially to assume full representation of all VISN internal stakeholders."; "The ELC should have external stockholder presence to provide input on special programs for identification and organization of major process and procedure lines at the network level."; and "Membership in the ELC should include a very broad representation of clinical management expertise to promote service integration and resource development."

Disapprove

Rationale: Composition of the ELC should not be mandated but determined by VISN needs.  The intent of the ELC is to have a wide range of members representing the key internal stakeholders.  VISN Directors will be charged with determining membership, however the suggestion will be passed on to those developing VISN Director orientation.

Comments: We also received numerous suggestions for the membership of the Management Assistance Council (MAC).  They included such groups as --  "a broad representation of the community health and social services network"; "For those members of the Puerto Rican community, will distance be taken into consideration?  We feel that it is important to have members of the Puerto Rican community included in the MAC since our health care program is quite different from that in Florida."; "Include mental health reps at this level.  Add Social Work representatives to insure community liaison and care to long-term patients."; "The MAC should include consumer groups beyond the VSO's such as the National Alliance for the Mentally Ill."; "Consideration should be given to relying of the State Veterans Service Commission staff instead of the VSO officers for meaningful input."

Disapprove

Rationale: A variety of advisory groups will be important to VISN management.  Actual membership to be determined as VISNs mature.  VSO's are vital to the success of VHA and will be actively involved.

Comments: "What is the Management Assistance Council's (MAC) authority and responsibility in addition to information collection?"

Rationale: The capacity of the MAC is advisory.  It will deal with wide range of issues from that advisory standpoint.

Comments: Other advisory councils were suggested.  These include the following --

"...Research Council to ensure that VISN management (a) is informed of all research activities, (b) is aware of the contributions of the research program to the VISN mission, and (c) receives advice regarding needed organizational changes as experience grows with the VISN structure.  This council should be chaired by an ACOS/R&D or equivalent and members should include representatives from affected universities, Veterans Service Organizations, Offices of Public Affairs, and others as appropriate, e.g., representatives from research regional office, field programs, and R&D centers."

"Establish a Mental Health Advisory Council for each VISN to insure coordination of services and eliminate duplication of programs.  Include Social Work representatives to insure coordination with community."

Disapprove

Rationale: Research input can be garnered in a variety of ways.  Need for councils should be evaluated as VISNs mature.  In order to offer flexibility, no specific councils are mandated.

Comments: "The Emergency Medical Preparedness Office has proposed the establishment of an Emergency Medical Preparedness Assistance Council, headed by an experienced EMPO Area Emergency Manager from a network facility within the VISN and assisted by other VAMC AEMs and/or Emergency Preparedness Coordinators, to advise and assist the VISN Director and staff in developing and conducting emergency management activities within the VISN.  Close coordination will be maintained with EMPO headquarters to coordinate approvals and integration of emergency preparedness activities that cross VISN boundaries."

Disapprove

Rationale: Need for Advisory Councils should be evaluated as the VISN matures.  It is, however, important that EMPO be an activity receiving high priority.

Comments: "Labor organizations are included as an external stakeholder in the MAC. Labor organizations must be involved as an internal stakeholder in these re-organizations."

Rationale: While union members are indeed internal stakeholders, unions themselves are external.  It is vital that strong partnerships be developed and highly positive working relationships be maintained with labor partners.

Proposed Revision:  No change is recommended at this time.  Labor partnership issue may need to be discussed by Headquarters for a policy or philosophy direction.


Recommendation:
2.3 VISN Directors will be accountable for meeting performance goals established in their performance contracts.

Action Required: 
2.3.1 establish and communicate VISN Director performance contracts (new action item)

Action Office: Chief Network Officer (13)

Target Date: 10/15/95

Comments: We received four comments regarding this recommendation.  One comments supported making VISN Directors accountable for the success of the VISN while another requested clarity in Headquarters and VISN roles in establishing performance criteria and standards.

Approve

Rationale: Refer to Performance Measurement Work Group.  Performance contracts will be jointly developed between the responsible parties.

Comments: One comment related to the VISN Directors Performance Contract period (Jan 1, 1996-Sept. 30, 1996) and  questioned whether this was sufficient time for VISN Directors to put their organizations in place.

Rationale: Decision for CNO.

Comments: The last comment was a lengthy set of questions related to employee education  --  "How will or should the VISNs interact with the Office of Employee Education?  What access will or should the VISNs have to the 10 Regional Medical Development Centers and 3 National Media Development Centers?  What level of funding and/or other support (NRM, equipment, FTE, etc.) should be allocated for employee education?  None of the reports include any reference to the VISN Director's responsibility toward employee education.  No performance measures are identified in regard to employee education. Yet, the Education and Training Work Group Report recommends that each VISN Director develop an educational plan, conduct a base line assessment at each network facility, develop measurement tools to assess organizational progress, and measure organizational progress toward culture change."

Approve

Rationale: Refer to Education and Training and Performance Measurement Work Groups.

Comments: "It is stated that contracting for services will require significant involvement as it becomes common practice experience has shown, in many cases, that contracting various services outside the facility has resulted in higher costs over time.  Cost effectiveness of contracting any service must continually be assessed."

Approve

Rationale: Agree in principle.

Proposed Revision: No change recommended at this time.

Recommendation:
2.4 Each VISN will be assigned three FTE as of October 1, 1995 (VISN Director, Clinical Services Manager).  Needs for other FTE will be developed and presented to the CNO for concurrence and will be made available from the FTE resource pool held by the CNO.

Action Required:
2.4.1 finalize position descriptions and functional statements

Action Office: VISN Activation Work Group

Target Date: 7/17/95		Actual Date: 8/3/95

Action Required:
2.4.2 classify positions and develop qualification statements

Action Office: Human Resources (05)

Target Date: 7/20/95		Actual Date: 8/3/95

Action Required:
2.4.3 identify strategies for recruitment process

Action Office: VISN Activation Work Group

Target Date: 7/20/95		Actual Date: 7/28/95

Action Required:
2.4.4 select preferred recruitment plan

Action Office: Under Secretary for Health (10)

Target Date: 7/20/95		Actual Date: 7/28/95

Action Required:
2.4.5 advertise through Centralize Staffing System and pertinent journals and publications

Action Office: Human Resources (05)

Target Date: 7/24/95

Action Required:
2.4.6  "request local examining authority from OPM" changed to "perform job analysis panel by OPM" (revised action item)

Action Office: Human Resources (05)

Target Date: 8/8/95

Action Required:
2.4.7 establish voice mail system to receive inquiries about the vacancy announcement and application procedures

Action Office: Management Support (163)

Target Date: 8/4/95

Action Required:
2.4.8 rank and rate applicants and develop best qualified (BQ) list

Action Office: Management Support (163)

Target Date: 9/8/95

Action Required:
2.4.9 provide BQ list to VISN Directors

Action Office:  

Target Date: 10/1/95

Action Required:
2.4.10 make selections

Action Office: VISN Directors

Target Date: 10/15/95

Action Required:
2.4.11 review and approve requests for additional FTE (beyond 3) for full VISN activation.  (new action item)

Action Office: Chief Network Officer (13) 

Comments: We received 26 comments regarding the VISN office staffing.  Three comments recommended a fourth position provide clerical support (a secretary or office manager position) to the VISN office.

Approve

Rationale: Clerical support will indeed be necessary, however, the VISN Director should have the opportunity to evaluate VISN organizational needs.

Comments: One comment recognized that the VISN Directors will have access to staff within their entire VISN, extracting staff from facilities within their VISN to perform needed functions.  They recommended " (1) FTE for only the VISN Director and allow this person to utilize facility staff at his/her discretion?  This would eliminate the need for the CNO to be involved with approving the hiring of the remaining (6 - 9) VISN positions."

Approve

Rationale: CNO will not be approving and hiring individual VISN staff, only in approving the organizational structure of each VISN.

Comments: Two comments disagreed that remaining VISN staff requires the concurrence of the CNO.

Disapprove

Rationale: As supervisor of the VISN Directors, the CNO has a need to know how each VISN will be structured.

Comments: "VISN staff will have dual responsibility for operations (day-to-day issues) and implementing change.  Operational issues may burden the staff to such an extent that implementing change may become a secondary task.  The change that is proposed is a major one.  How are the staff of the VISN and the facilities to be educated and trained to make this transition?  The tasks currently performed by the Regions are formidable.  It would be advisable to recommend/suggest those tasks that could be performed by the facilities and those task to be performed by the VISNs.  The tasks to be performed by the VISNs could be grouped into organizational areas that would logically lead to positions of responsibility, i.e., staff."

Approve

Rationale: (1)  Organizational needs to be evaluated by VISN Director.
(2)  Transitional issues will be a major concern of CNO and VISN Directors.
(3)  Expertise throughout the VISN will be tapped to accomplish the mission.

Comments: Six comments recommended that there be a designated nursing presence at the VISN level or that we mandate that the Clinical Services Manager is a nurse.

Rationale: Opportunity exists for registered nurses to apply for the position of Clinical Services Manager and for registered nurses to be a part of Executive Leadership Councils.

Comments: One comment suggested that the Clinical Services Manager should go to a physician "since the appointee should serve as advisor for all clinical programs and have oversight responsibility for contracted service providers (e.g., University physicians contracted services)."

Rationale: Physicians have the opportunity to apply for both VISN Director and Clinical Services Manager.  Other clinical disciplines would also have the needed expertise.

Comments: One comment recommended that the VISN include representation by a Physician, Nursing, Pharmacy and Social Work.

Approve

Rationale: Opportunities for representation do exist.  It would be anticipated that a number of advisory bodies would emerge involving key clinical stakeholders.

Comments: One comment was concerned with the crucial balance to outplace Region and Headquarters staff with the need to allow the VISN Directors the ability to select a few key staff who will work as a cohesive unit.  "Employees without the appropriate knowledge and skills will be detrimental to the VISNs mission."

Approve

Rationale: VISN Directors will select all VISN staff.

Comments: One comment questioned, "What impact does the restructuring have on Regional Nurse Professional Standards Board, i.e., areas of responsibility, mechanisms to process; who is accountable at the VISN level, etc.?  Please clarify.  Product lines include various specific patient care programs.  How will other patient care programs be affected by the restructuring?  Patient care is the focus of restructuring and will be affected either directly or indirectly by each restructuring component and each decision made.  Therefore, a representative of nursing should be at the table; part of the group in the new structure."

Approve

Rationale: Nurse Professional Standards Boards will need to be addressed as a part of the transition.  Clinical Services Manager is an important position with much responsibility and authority (see position description in Appendix 5 of report).  Nurses have opportunity to apply for this position.

Comments: One comment recommended that the CFO participate in selection of and concur with appointment of VISN Financial Managers to strengthen the relationships between the CFO and VISNs.  ("What is the intended relationship between CFO and VISN CFOs?")

Approve

Rationale: VISN Directors may seek CFO input at their discretion.  However, the VISN Financial Manager is responsible to the VISN Director.  It will be very important to establish and maintain effective and positive working relationships with the CFO and his staff.

Comments: Two other specific functions in the VISN were recommended:  (1)  "Although strategic planning is listed as a core responsibility of VISNs, planning staff is not included as part of the core VISN staff."  (2) "Recommend a CIO function at each VISN, either as a full-time position or collateral duty of VAMC or VSSC employee.  Responsibilities would include coordination of IRM activities at field facilities and informatics/database activities at VSSCs."

Approve

Rationale: (1)  The planning function can be undertaken in a number of ways including utilizing existing planners at VISN facilities or the employment of a planner within the VISN office itself.  (2) A CIO position has been recommended, either in the VISN office or within the VISN, as determined by the VISN Director.

Comments: One comment questioned the announcement of the Clinical Services Manager and Financial Manager positions prior to selection of the VISN Directors.  "This will provide a pool of applicants for VISN Directors to selection from and expedite the process.  While this approach will minimize delay in establishing key positions in each VISN, it may also preclude some people from applying for these positions since they will not know for whom they will be working."

One comment questioned why the VISN Directors were not involved in the process of selecting Clinical Services and Financial Managers?

Approve

Rationale: The benefit of having these key persons available as soon as possible after the selection the VISN Director was felt to outweigh the disadvantages. 

Comments: One comment suggested that expediting the recruitment and selection processes for VISN Clinical Services and Financial Managers contradicts allowing VISN Directors maximum flexibility in determining their specific organizational structures and staffing requirements.

Disapprove

Rationale: (Basic organizational decisions were made while attempting to allow maximum flexibility for VISN Directors.  VISN Directors will have maximum flexibility in determining remaining VISN staff but these two positions were determined to be critical for all VISNs.

Comments: Three comments related to the requirements for the Clinical Services Manager.  (1)  "Recommend that education requirements be more specific for VISN positions.  Generally, a Master's Degree would be the minimum."  (2) "It is very important that the incumbent have knowledge and skills that will promote the development and expansion of community services and resources needed to support VHA health care objectives."  (3) " The position description limits this position to physicians or nurses.  Given the responsibility of this position other clinical staff  with the requisite experience and expertise should be afforded consideration for this critical community-interactive role."

Rationale: 
(1) D Maybe desirable but cannot be required.
(2) A The social service requirements for Veterans will be an integral part of Clinical Services management.
(3) A The intent was to limit the position to those professions covered by Title 38.  Within the designation, only physicians, dentists and nurses were deemed to have the appropriate educational backgrounds and skills required for the position.

Proposed Revision: Add additional action items as suggested above.


Recommendation:
2.5 VISN Directors will select, once the organizational plan is approved by the CNO, all their staff.

Action Required:
recruit and select VISN staff

Action Office: VISN Directors

Target Date: 1/1/96

Comments:  None
Proposed Revision: No change recommended.


Recommendation:
2.6 Utilize those individuals currently in "Operations" to provide primary assistance on a time-limited basis to achieve deactivation of regional offices, conduct analyses relating to the elimination or reassignment of current regional activities and provide support for outplacement of staff.

Action Required:
*2.6.1 assign Region staff to Chief Network Officer

Action Office: Chief Network Officer (13) 

Target Date: 10/1/95

Comments: "The VISN Activation Plan contains detailed recommendations for issuing press releases, resolving property management questions, renovating offices, and hiring senior staff.  However, an orderly process for managing program duties during the transition, and providing administrative and financial support for those activities, is missing."

Disapprove

Rationale: The plan specifically addresses the orderly transition by transferring all Region staff to the CNO during the transition phase.

Comments: "Recommendation to utilize existing staff in 'Operations' -- Existing staff and their corresponding functions within the current 'Operations' structure include individuals assigned primary duties as the operations 'budget' person and operations 'planning' person.  Under the new paradigm being introduced by the Vision for Change, Headquarters program offices are being challenged to redirect their thinking and actions toward a field customer orientation.  The new CNO organization should support this new orientation and rely directly upon the CFO for budget support.  This will foster Headquarters team building and eliminate duplication of functions within Headquarters.  Positions such as planner and budget/resource manager are inappropriate and duplicative within the new CNO organization."

Rationale: (1)  The need for cooperation between the VISN and Headquarters is stressed in the new organization.
(2)  There will be a need for on-site budget and planning expertise in the VISN to deal with daily operational issues.

Proposed Revision: No change recommended.


Recommendation:
2.7 As soon as deemed possible, appoint members of the VISN Support Team in order to have them on-board to assist with VISN activation and provide immediate interface with the Office of the Chief Network Officer.  Team members will also be available to assist newly appointed VISN Directors in their orientation, establishing VISN offices and providing immediate support with other transition activities.

Action Required:  *2.7.1 designate routing symbols, T&L numbers, etc.

Action Office: Policy & Planning (005) and Mgmt. Support office (163)

Target Date: 10/1/95

Action Required:  *2.7.2 orient VA facilities to transition plan

Action Office: Chief Network Officer (13) 

Target Date: 9/8/95

Action Required:  *2.7.3 orientation with VISN Directors and key staff

Action Office: Chief Network Officer (13)

Target Date: 9/7/95

Action Required:  *2.7.4 establish regular conference calls between Chief Network Officer

Action Office: Chief Network Officer (13)

Target Date: 10/2/95

Action Required:  2.7.5 evaluate Region and decentralized Headquarters functions and determine disposition

Action Office: Chief Network Officer (13)

Target Date: 3/31/95

Comments:
We received 30 comments regarding this recommendation.  Most of the comments addressed how our VISN Support Staff model conflicted with that model suggested by the Headquarters Restructuring Work Group.  Additional comments include: "Both appear to want to address the operations/ clinical schism which proved to be enervating, at least to many clinical staff, following the last reorganization."; "The VISN support team concept is sound but will only function well if the people are capable and understand that their mission is to support the VISN offices."; "The success of this is dependent on the success of the implementation of a 'flat' rather than a hierarchical organization."; "Relationship between VISN and SHG offices, in terms of their roles/responsibilities with clinical programs, needs to be fully described."; "We have concern that this support would not be responsive to the needs of the VISN but would continue the current hierarchy.  This could easily lead the 'support' services to drive the efforts of the VISN rather than provide consultation and resource."; "If decisions/responsibility/actions are decentralized, VISNs would not need technical experts for advocacy in Headquarters, unless Headquarters plans to dictate to VISN directors."; "Expertise should be provided in as many diverse (and critically important) areas as possible (i.e., have 11 distinct subject areas).  Consider replacing redundant subject areas such as admin. and clinician with Quality Assurance, 'Safety' and the Information Management since questions in these areas arise from time to time and this type of in-house expertise within the Office of the CNO could be beneficial."; "Some reference to the desirability of research expertise on the VISN support team would be helpful."; "The VISN support team as described here is a useful mechanism to advise the CNO and provide a primary contact point for each VISN.  The HQ group recommendation is a stronger mechanism for integrating across HQ product lines and disciplines and provides stronger contact in HQ for VISNs.  The two ideas can he combined."; "Eliminate VISN Support Team.  This is a valueless layering and perpetuation of present operation model.  Adds to bureaucracy."; "The idea must be conveyed that the VISNs, Headquarters and the individual facilities are a team, each with responsibility and authority even if performing staff functions."; "One lesson learned from VA's involvement with National Health Care Reform and VA's implementation of the proposed reform was that the intermeshing of the clinical manager's perspective resulted in recommendations that were both patient-centered and cost effective."; "I agree with the team approach concept, however, I support advertising the positions together with competition for membership on the teams (not reassignment of current Operations HSS staff)."; and "Since EMPO develops policy, implements programs, maintains and coordinates strategic and operational emergency (or contingency) planning at national, network, and local levels for VHA and VA, a close working and coordinating mechanism between designated EMPO Headquarters staff and VISN Support Team must exist."		

Approve

Rationale: After meeting with the Coordinating Committee, the Headquarters Restructuring Work Group "VISN Support Team" model was accepted.	

Proposed Revision: edit the document to reflect the VISN Support team as recommended in the Headquarters Restructuring Work Group Report (Five teams, each composed of 12-14 members; each team will support one or more VISNs).

Action Office: HQ Restructuring Group

Target Date: 8/29/95


Recommendation:
2.8 Since the primary purpose of service centers is to support VISNs, they should be formally titled "VISN Support Service Centers (VSSC)".

Comments:  None

Proposed Revision: No change needed.


Recommendation:
2.9 Establish four VSSCs at existing region locations.

Comments: Of the seven comments received on the VSSCs, all supported the elimination or reduction of the VSSCs.  Specific concerns include the following:  "While the report initially argues for not replicating the services now provided by the Regional offices, the regionally located support centers will result in this undesired outcome.  I predict that Quality, Safety, Construction, Risk Management and other staff who currently provide oversight than service will continue doing the same jobs under new titles."; "Eliminate VISN support centers.  This is a valueless layering and perpetuation of present operation model.  Adds to bureaucracy."; "Although for a few months VSSCs could be supportive of routine business during transition, many functions should be transferred to the VISN or be field based."; "The proposed Board of Directors for the various VISN Support Service Centers (VSSCs) seem to mirror the existing Regions."; "I am also concerned that the VISN offices housing these VSSCs will somehow take on a greater aura of importance that VISN offices with no special emphasis programs.  I recommend that all VSSC activities be consolidated in a central location in the country, geographically separate from any VISN office."; "With a limited staff, it will be very difficult for a VSSC to adequately provide the highly specialized expert technical and consultative services in addition to the required data development, analysis and consolidation functions."; "I see the need for at least 2 VSSCs:  financial and education.  All the rest can be done at the VISN level."

Rationale: The issues of SSCs continues to need discussion and refinement.  The Vision For Change clearly defines their existence and locations.  Work group discussions identified that this may be a transitional need and once all VISNs are operational, the need for VSSCs may disappear--hence the recommendation that they be established only if there is a "value added" need.  The suggestion that there be a single VSSC may have merit, however until a full analysis of the continued need for existing Regional functions is completed, no decisions regarding structure and placement of VSSCs should be finalized.

Comments: "Under paragraph titled Consultation, examples of services that might be included as VSSC functions include risk management and quality assurance.  Many of the traditional quality assurance functions are already transitioning towards organization performance and it might be worth while incorporating many of the current functions into planning and performance.  This is true for risk management as well although to a lesser extent.  However, there is probably a continued need for some kind of JCAHO accreditation consultants and these roles might well be suited to VSSCs.  I think it fairly important to not separate quality assurance functions from planning and performance.  That almost invites duplication of efforts."

"I question the need for 4 VSSCs.  I support the VISN directors with small staffs, and cross functional work groups providing information, roll-ups and so on. I am making the assertion that we attain a high level of data base integration, and advance computer programming and platforms in order to perform these functions."

Approve

Rationale: Roles will be determined during the transition phase.

Proposed Revision: No change is recommended at this time.


Recommendation:
2.10 Adopt VSSC core functions as consultation and data development/analysis.

Comments: Of the five comments we received, two comments disagreed to maintain staff in the VSSC to provide high quality technical and consultative support functions.  "We have that expertise within each facility."  One comment questioned the need for VSSCs and the final comment recommended that the VSSCs "should prepare reports, manage databases, and provide technical expertise in accessing VHA databases.  Recommend that region staff who currently perform these functions be carried to the VSSCs."

Disapprove

Rationale: Roles and staffing of the VSSCs will be determined at a later date during the transition phase.

Proposed Revision: It is suggested that all VSSC recommendations be combined.


Recommendation:
2.11 Align VSSCs organizationally under VSSC Board of Directors.

Action Required:  2.11.1 establish four (4) VSSC Board of Directors.

Action Office: Chief Network Officer (13)

Target Date: 10/15/95

Comments: "The report indicates VISNs and VSSCs are to be configured to draw upon the expertise within a give geographic area to perform necessary tasks.  No where is it implied or stated that VISNs will draw upon staff in VSSCs outside their geographic area (i.e., VISN 22 will rely on service within VISN 22 and/or the VSSC in San Francisco; VISN 22 should not have to call on staff in any other VISN or VSSC for assistance.  Therefore, it is critical that key functions area available throughout the country and located such that each geographic area has access to those critical functions (either via their local VSSC or within their respective VISN)."

Disapprove

Rationale: The exact configuration of the VSSCs has not been determined.  During the transition phase it will be decided how to best configure the VSSCs.  The intent would be that they provide a value-added service for multiple VISNs.

Proposed Revision: Suggest combining all VSSC recommendations.


Recommendation:
2.12 Determine exact staffing mix for the VSSCs after VSSC Boards of Directors are established, local needs are determined and region functions are assessed/revised.

Action Required:
2.12.1 begin recruitment of VSSC staff

Comments: "What is the intent that the host VISN will provide administrative support to the VSSC?"

Rationale: Logistically easiest.

Comments: Of the 10 comments submitted, most were concerned with the limitation of staff at the VISN and VSSCs and the functions these offices will perform.  "VISNs should have sufficient resources within their respective network and/or within their supporting VSSC to achieve VHA's goals."  "Increasing staff within a VSSC must be a viable option.  But rather than choosing an arbitrary figure of 7 to 10 staff at the VISN and 13 staff at each VSSC, place no restrictions on FTE.  If FTE restrictions are necessary, place them on the networks (collection of facilities, VISN and pro-rated portion of the VSSC).  Mandating FTE encumbers the VISN Directors."  "A maximum number of FTE (52) should not be prescribed as needs should dictate staffing."  "The VISN Board of Directors should have the flexibility to establish the numbers of FTEE per VSSC including the type positions and their selections."  "I agree that VISN directors should take part in the review and recommendation of VSSCs."  "Given the nature of tasks anticipated for the VSSCs, I think it unlikely all can perform the same function with only 13 staff."  "Will VISN Directors be willing to delegate the authority to provide specific guidance to those at the VSSCs, or will we often grind to a halt while our technical advisors 'check with the VISN,' or will the opposite happen and we wait while the VISN Director's staff seeks technical guidance?  I see this slowdown as extremely likely in the construction area, especially if the VISN Director does not employ a construction manager."  "I agree they should not be the 'ghost of region's past.' Fire/Safety, IH, CM may be appropriate roles."

Rationale: Clerical staff are included in the 13. The nature of the tasks for VSSCs has yet to be determined.  It is conceivable that tasks originally identified for VSSCs in Vision For Change may be assigned elsewhere. The need for and best way to accomplish current and future programs will be considered during the transition phase.  VSSCs staff will be consultative only, other than technical expertise.  They have no decision making authority

Proposed Revision: Recommend combining all VSSC recommendations.


Recommendation:
2.13 Create a structure for VSSCs that is flexible and enables the organization to evolve as needs and requirements change.

Comments:  None

Proposed Revision: Recommend combining all VSSC recommendations.


Recommendation:
2.14 Do not include in VSSCs those functions/services that are primarily designed to support VHA Headquarters (e.g. Boston Development Center, Decision Support System).

Action Required: 2.14.1 determine functions to be assigned to VSSCs

Action Office: VSSC Board of Directors

Target Date: 3/31/96

Comments:  None

Proposed Revision: Recommend combining all VSSC recommendations.


Recommendation:
2.15 Allow VISNs and facilities to shape the future of other consolidated programs (such as Consolidated Mail Outpatient Pharmacies, Central Dental Labs) based on their willingness to purchase services that are high quality and cost efficient.

Comments: "It would be noted that it requires significant resources, time, effort and dedication to establish an efficient and cost effective consolidated program.  The savings and cost efficiencies achieved by these programs should provide benefits on a long-term basis and in many cases, our system planning is completed on more of a short-term basis with the focus on immediate returns."

Comments: "In the establishment of VISN support services centers as a centralized group or as transitional offices, some service centers should be considered unique to clinical specialties.  The out-placed National VA Chaplain Center with its Chaplain School component should be considered such a resource."

Approve/Disapprove

Rationale: The differences between specialized centers and VSSCs is noted.  The need for other type centers will be evaluated.

Proposed Revision: No change recommended.


Recommendation:
2.16 Colocate VISNs with VA Medical Centers in Boston, MA; Albany, NY; Bronx, NY; Pittsburgh (HD), PA; Bay Pines, FL; Cleveland, OH; Chicago (Hines), IL; Minneapolis, MN; Portland, OR; and Long Beach, CA VISN sites.

Action Required/Action Office/Target Date:
*2.16.1  prepare press releases to announce VISN sites	
Public Affairs Office (80)	8/7/95

*2.16.2  forward letter to host facilities regarding support for VISN activation activities	
Chief Network Officer (13)	8/7/95

*2.16.3  issue authorization letter and TDA	
Chief Network Officer (13)	8/7/95

2.16.4  start A/E procurement; advertise for A/E; select A/E; negotiate A/E cost; award A/E design contract	
host facility	8/31/95

2.16.5	complete design and contract documents	host facility	10/15/95

2.16.6	advertise for construction bids 
host facility	10/22/95

2.16.7  open construction bids	
host facility	12/8/95

2.16.8  award construction contract	
host facility	12/15/95

2.16.9  start construction	
VISN Office Activation Team	12/31/95

2.16.10  complete construction; occupy VISN office	
host facility	3/3/96

Comments: "The plans to establish office space prior to selection of VISN Directors is understandable due to the lead time necessary to obtain such space.  However, in some instances new leased space will be identified in a community before the VISN Director is able to have any input into the process.  While the VISN Directors will not have any choice regarding the city in which the VISN office is to be located, it would be nice if the VISN Director could have some control over the exact location of the office within the selected community.  If this cannot be done, then factors such as proximity to the airport, community distances, and proximity to those with whom the VISN staff will be doing business should be carefully considered when selecting the site."

Disapprove

Rationale: The logistical requirements for establishing VISN Offices require that decisions be made as to their locations as soon as possible.  The Work Group deliberated this issue and determined that VISN offices should be established utilizing pre-established criteria.

Comments: "The reason site selection information is not included in this report is unclear, as the report itself is only a draft report.  Comments on recommended sites may be useful during the approval process."

Approve

Rationale: The site selection information was not included in the Report since this it required management approval.

Comments: "VISN offices need to be located centrally for easy access."

Approve

Rationale: This has been considered in the site criteria.

Proposed Revision:  None

Recommendation:
2.17 Colocate VISNs with other existing VA functions in Durham, NC; Nashville, TN; Kansas City, OH; and Phoenix, AZ VISN sites utilizing the amended lease process.

Action Required:
2.17.1 prepare reimbursable work authorization to GSA for renovating space, if necessary (new action item)

Action Required:
2.17.2 notify GSA regarding leasing action and agree to additional renovation costs, if necessary (new action item

Comments:  None


Recommendation:
2.18  
Action Required/Action Office/Target Date:
*2.18.1  review bid proposal(s) and determine most advantageous to VA	
host facility	9/8/95

*2.18.2  submit best bid to professional appraiser; complete GSA form 1241E	
host facility	9/8/95

*2.18.3  submit bid for legal review to District Counsel	
host facility	9/8/95

*2.18.4  receive professional appraisal and legal review; execute lease	
host facility	9/14/95

2.18.5  lessor work with VA to prepare build-out space	
host facility	10/16/95

2.18.6  inspect space for suitability	
host facility	10/17/95

2.18.7  occupy space	
host facility	10/24/95

Comments:
Three comments were concerned that the new leases will require expedited lease authority.  "The Action Plan should make it clear that local funding for all lease costs must be available at the host facility, or the leased space cannot be procured locally.  In addition, the space must be under 10,000 net usable (now 'occupiable') square feet, and cost no more than $300,000 annually, or VA Central Office must procure the space, unless VACO specifically delegates authority for that lease to the host facility."

Approve

Rationale: Expedited lease will be used within the limits of the expedited lease authority.

Comments: "With respect to leasing VISN property, the use of expedited leasing procedures may not be appropriate for some of the VISN leases because the build-out required may be too extensive.  Therefore, reference to standard negotiations procedures should be made in the Action Plan."

Approve

Rationale: At the present time, build-out requirements for lease space is not anticipated to be significant.

Comments: "The Action Plan for leasing should be consistent with Directive 10-94-057.  Therefore, insert the statement that a copy of the executed lease and supporting documentation will be forwarded to the Director, Real Property Management Service (084) for inventory control purposes."

Approve

Rationale: These comments were included in the Draft report but not distributed.

Comments: "Add a new box for the following action: 'conduct a site visit and negotiate unique requirements.'  The box should be inserted between 'conduct market survey of the proposed site,' and 'distribute short form ... bid proposals.' "

"The Action Plan should make clear that the Offices of the General Counsel and Acquisition and Materiel Management should be consulted and participate in any reviews and approvals routinely necessary.  This is of particular importance because of the possible need for certain waivers for the expedited procedure envisioned."

Approve

Comments: "Contracting issues (including leasing) must be dealt with as soon as possible in order to make the stated transitions in a timely fashion.  The Office of General Counsel and appropriate contracting officials should be included in any future working groups to help identify and address contracting issues at the earliest possible time."

Approve

Rationale: The VISN Activation Team, whose purpose is to coordinate renovation and leasing activities, includes representatives from Management & Field Support Office and Real Property, but does not include Acquisition & Material Management and General Counsel.  CNO will consider including these offices.

Proposed Revision:   None


Recommendation:
2.19 Establish VISNs in Baltimore, MD; Ann Arbor, MI; Jackson, MS; San Francisco, CA; and Dallas, TX utilizing existing Region leases

Action Required:
2.19.1 modify lease for new space configuration, if necessary (new action item)

Action Required:
2.19.2 prepare supplemental lease agreement for renovation, if necessary (new action item)

Comments:  None

Proposed Revision: None


Recommendation:
*2.20 Establish a VISN Office Activation Team in Headquarters to coordinate renovation and delegated leasing activities for the preparation of VISN office space.  This team should include representatives from the Engineering Management and Field Support Office (138) and Real Property Management Office (084) and be coordinated by the CNO office.

Comments:  None


Recommendation:
*2.21 Set aside funds in Headquarters to cover renovation and lease costs (FY95/96 NRM funds and All Other, respectively).  Once VISN office locations have been approved, TDAs should be sent directly from Headquarters to host (or other designated) facilities to begin planning and design for projects and negotiations for leases.
Comments:  None


Recommendation:
2.22   Reassign certain Region furniture and office equipment to VISNs and VSSCs in Baltimore, MD; Ann Arbor, MI; Jackson, MS; and San Francisco, CA.  Maintain an inventory of remaining Region furniture and equipment as it becomes available for excess and give priority consideration to redistributing it to new VISNs.  Allow new VISNs to purchase furniture and equipment if excessed Region items are not suitable or available in a timely manner.  Set aside funds in Headquarters to support furniture and equipment purchases.  Redistribute unassigned Region furniture to other facilities within the system utilizing existing excess property programs.

Action Required/Action Office/Target Date:
*2.22.1  distribute funds for procurement of furnishings and equipment to Regions	
Chief Network Officer (13)	8/7/95

*2.22.2  determine specific requirements and identify sources for procurement; draft orders	
host facility	8/7/95

2.22.3  develop plan showing location of furnishings and equipment; determine resource requirement
host facility	8/14/95

2.22.4  submit orders (2237) to host facility A&MM (90) for processing	
host facility	8/21/95

2.22.5  install furnishings and office equipment to occupy space	
host facility	1/5/96

Comments: "The VISN Activation Work Group provided a schedule for VISN office site selection, design, remodel of offices, procurement of office furniture, etc.  That schedule will not provide adequate facilities fast enough for VISN directors to set-up their offices and begin functioning."

Rationale: We recognize the importance of activating VISNs in a timely fashion; every effort will be made to make this occur.

Proposed Revision:  None


Recommendation:
2.23 Pursue video conference equipment capability for 22 VISNs and the Office of the CNO.  Charge MIRMO with coordinating the specifications for video conference equipment and coordinating equipment purchase, installation, and training.

Comments:  None

Proposed Revision: No change recommended at this time.

Recommendation:
2.24 Develop and submit a legislative initiative to deal with salary discrepancies for senior management staff including VISN Directors and others between Title 38 and SES and within Title 38.

Comments: Several comments were received, all supporting this legislation.  Additional comments include:  "The most significant of these would be the salary differential that would exist between physicians and others who would all be doing essentially the same jobs."; "If legislative initiative is introduced to correct the discrepancy between Title 5 and Title 38 for VISN Directors, it should also include the discrepancy presently existing for Medical Center Directors."; "OMB Circular A-19 requires that before VA makes available to Congress or the public any proposal for or endorsement of Federal legislation, the proposal or endorsement must be submitted to the Office of Management and Budget for coordination and clearance.  This report would thus need to be cleared by OMB before it is released to Congress or the public."

Approve

Rationale: The recommendation was specifically developed to deal with this concern.  The focal point of the committee was for VISN activation.  The concern identified may need to be reviewed within a different arena.

Proposed Revision: Change recommendation as above and add actions items indicated.


Recommendation:
2.25 Region offices will be immediately charged with developing VISN specific "Transition Resource Guides".  These guides will be assigned to the Regional Directors by the AsCMD for Operations to be completed by September 30, 1995 or sooner.

Action Required:
*2.25.1 develop "Transition Resource Guides"

Action Office: Regions

Target Date: 9/30/95

Comments: "Copies of Transition Resource Guides with VISN-specific data should also go to HQ offices, including SHG offices."

Rationale: Agree

Proposed Revision: No change recommended at this time.


Recommendation:
2.26 Effective October 1, 1995, Region employees will be operationally realigned to the CNO, but will remain on the Medical Care Appropriation account; Region functions will be transitionally realigned to the Office of the CNO.  A process of critically evaluating Region functions will begin immediately.  (Disposition recommendations for all functions will occur no later than March 31, 1996).

Comments: We had 19 comments on this subject.  Some of the comments included:
"Careful consideration must be given to Region staff during the transition process to demonstrate the assertion that 'VHA's employees are perhaps the greatest strength of the organization.'  To more effectively utilize staff, productively standards should be implemented and cross training should be explored where appropriate.

Approve

Rationale: Every attempt will be made to be as employee-sensitive as possible as evidenced by the planned outplacement program.

Comments: "During transition the CNO supervisory span of control (Region staff, SSC staff, etc.) may become unwieldy, alternatives may need to be considered."

Approve

Rationale: Alternatives will be developed as necessary during the transition. 

Comments: "How realistic is it to retain regional offices for 6 months as functions are being reviewed?  Won't most good staff leave for other positions?"

Approve

Rationale: The intent is not to maintain regional offices.  Time frames are tight but we believed that moving quickly is essential.

Comments: "The transition process appears too hurried."

"I am troubled that the 'plan' fails to identify what office(s) within the new organization will be responsible for carrying out the 440 tasks currently performed by regional offices.  I agree that it makes sense that VISN support centers be established at existing region locations.  But it makes no sense to leave unresolved the assignment of responsibility for current region responsibilities and allow for additional functions to evolve at the new centers, while planning for only a marginal number of support center staff."

Disapprove

Rationale: To assure a smooth transition from the current structure to VISNs, all current region functions will continue until they can be analyzed and either reassigned or eliminated.  Careful consideration is planned to determine the appropriate organizational placement for tasks currently assigned to region staff.

Comments: "The region construction attorneys have served as effective in-house counsel.  We believe that service should continue at that level."

Approve

Rationale: The region construction attorneys have served as effective in-house counsel.  We believe that service should continue at that level.

Comments: Some comments provided suggestions and other recommendations such as the following:
"One option available is to use these staff for a specific period of time to perform their current duties, then ask them to train (or become) VISN or facility staff performing these functions."

Disapprove

Rationale: Staff will be reassigned to the CNO upon the activation date.  These staff will participate in evaluation and realigning functions as appropriate until VISNs are operational and functions are either realigned or eliminated.

Comments: "I am concerned that all the requirements of the various work groups may not be doable.  I would suggest that a special work group examine the entire document from 'an executive point of view' to identify those functions which must absolutely be performed if the VISNs are to be successful.  It would be much better to do a few tasks and do them well than to attempt too many tasks and, as a result, do them all poorly."

"The Region functions recommended to be transferred to VISNs are very vague.  In keeping with the concept of management flexibility, the VISN Director should determine how best to accomplish necessary functions."

Approve

Rationale: The intent of the transition process is to allow for adequate review of existing functions in relation to their elimination or reassignment to VISNs, VSSCs or Headquarters.  These comments will be provided as a part of the VISN Resource Guide.

Comments: "We realize that the working group report does not get to this level of functional detail, but we thought the working group should consider either:  (1) mentioning the VISN formulary process as an example of a new function (previously managed at a medical center) and/or (2) adding action items to the report which would instill the VISN formulary into the first phase of VISN activation."

Approve

Rationale: This suggestion has merit and should be considered during the transition process.

Comments: "Region staff should be included in the evaluation of Region functions to insure familiarity with subject matter." 

Approve

Rationale: The intent would be to involve those knowledgeable about current functions.

Comments: "This report recommends that Region employees be operationally realigned to the Chief Network Officer but continue to be paid from the Medical Care appropriation.  Application of the support function versus direct operation rule in this case would require consideration of the function of these Region employees after they are realigned to the Chief Network Officer.  If their function would involve the operation of the VA system nationwide, this would be a support function which must be funded from MAMOE.  If, on the other hand, the function of these employees would involve the operation of VA facilities on a State-by-State, region-by-region, or facility-by-facility basis, this would be a direct operation function which would have to be funded out of Medical Care funds.  Before this report is issued, therefore, the function of these employees should be examined."

Rationale: This issue needs clear interpretation.  The intent is that the role of region staff would not change nor would the reporting relationship to Headquarters via the CNO (previously the AsCMD for Operations).  The only change would be the absence of the region per se and a Regional Director during the brief phase-out period.

Proposed Revision:  None


Recommendation:
2.27 Seek expedited approval of the Decision Paper on the Special Placement Program from the Under Secretary for Health.

Action Required:
*2.27.1 expedite approval of decision paper on special placement program

Action Office: Chief Network Officer (13)

Target Date: 8/1/95

Comments:  None

Proposed Revision:  None


Recommendation:
*2.28 Implement the Special Placement Program at the end of the Congressional waiting period.

Action Required/Action Office/Target Date/Actual Date:
*2.28.1  implement special placement program	
Chief Network Officer	8/7/95	9/7/95

*2.28.2  issue letter informing Region employees of office closures	

Under Secretary for Health (10)	8/7/95	8/17/95
*2.28.3  issue letter implementing special placement program	
Chief Network Officer (13)	8/7/95	9/7/95

*2.28.4  issue letter to all facility Directors and VAMC activities, Regional Directors, OPCs and ROs with OPCs regarding provisions of special placement program	
Chief Network Officer (13)	8/7/95	

*2.28.5  survey Region staff for preferences and mobility	
Regions	8/25/95	

Comments: Of the five comments received, most provided positive support to the outplacement efforts for Region staff.  However, they added such comments as "...will be difficult due to downsizing of the work force in the federal government as well as the private sector, and without transfer of Region FTE.  It also may be difficult to outplace Region staff in an expeditious manner under current and projected budgetary constraints."; "This [outplacement] has occurred in the past and is an effective benefit if outplacing staff is to be accomplished expeditiously, especially with buy out authority unlikely.  Otherwise, it may be difficult to place staff at higher grades or specialized expertise."; "May need to place the staff in Medical Centers or ensure buy-outs and early-outs are attractive, especially for grades GS-13 and above."

Approve/Disapprove

Rationale: VHA will require full cooperation from all entities to assist in absorbing region staff through the special placement program.  The provision of FTE with outplaced staff is not possible due to budgetary constraints. FTE will be reassigned to support the new structure.  Outplacement has been utilized on a very limited basis within VHA in the recent past.

Comments: "The Special Placement Program to assist staff with buy out and early out is commendable.  Along these same lines for those of us who are mobile, an electronic data base that would reveal housing for sale or rent by vacating VA employee, would expedite the move-relocation of the transferee."

Approve

Rationale: This suggestion will be provided to the special placement program managers for consideration. 

Proposed Revision:  None


Recommendation:
2.29 Use Special Placement Program developed for region staff as a model for planned parallel efforts for Headquarters employee outplacement. (revised recommendation)

Comments:  None

Proposed Revision:  None


Recommendation:
2.30 Request specific "buy-out" (Voluntary Separation Incentive Payment) authority as an incentive for increasing attrition.

Action Required:
*2.30.1 prepare buy-out authority request

Action Office: Management Support (163) 

Target Date: 8/1/95

Action Required:
*2.30.2 request buy-out authority (VSIP)

Action Office: Management Support (163)

Target Date: 8/7/95

Comments: "Report references need for early out and buy out authorities.  Early out authority has been approved through 9/30/96; buyouts would require legislation, and we do not anticipate favorable consideration from OMB at this point."

Proposed Revision:  None


Recommendation:
2.31 Request an extension of the "Early Out" (VERA) authority.

Action Required:
*2.31.1 request extension of Voluntary Early Retirement Authority

Action Office: Management Support (163) 

Target Date: 8/7/95

Comments:  None

Proposed Revision:  None


Recommendation:
*2.32 Provide all Region employees waiting to relocate a "bona fide" job offer of assignment, at grade and pay retention as a minimum, to a position in VHA although not necessarily in accord with employee preferences, prior to use of RIF procedures or other separation authorities.

Comments:  None

Proposed Revision:  None


Recommendation:
2.33 Remain cognizant of Labor Management considerations and the need to communicate with the VHA National Partnership Council as employee outplacement issues continue to evolve.

Action Required:
2.33.1 notify Partnership Council of program parameters

Action Office: Under Secretary for Health (10)

Comments: "Labor partners are indicated as stakeholders, but has anyone contacted them regarding the impact of eliminating some of the current regional functions (e.g., EEO, Fire and Safety, Industrial Hygiene)?  For example, the AFGE National Agreement indicated Regional Safety staff will conduct the annual OSH inspections.  Should these positions be dramatically reduced or eliminate altogether, how will VHA honor its part of this agreement?"

Rationale: The National Partnership Council has representatives on the VA Management Assistance Council and the Coordinating Committee for this project.  In addition the purpose of this recommendation is to ensure appropriate consideration be given to labor/management issues including existing agreements.

Proposed Revision: No change is recommended at this time.

Target Date:  Ongoing


Recommendation:
2.34 Immediately activate ADP Bulletin Board System to be accessed by all Region and Regional Division Offices composed of the following:  an employment survey instrument to state location and occupation preferences; a resume library which may be reviewed by prospective employers; and, a list of applicable VHA vacancies.

Action Required:
*2.34.1 utilize IRM/ADP bulletin board system

Action Office: Regions

Target Date: 8/7/95

Comments:   None

Proposed Revision:  None


Recommendation:
2.35 Widely disseminate the Employee Handbook developed by the Office of Human Resource Management.

Action Required:
*2.35.1 distribute employee handbook

Action Office: Chief Network Officer (13)

Target Date: 8/7/95
Comments:   None

Proposed Revision:  None


Recommendation:
2.36 Activate Outplacement Centers and coordinate outplacement activities at all Region sites.

Action Required:
*2.36.1 activate outplacement centers located at Regions

Action Office: Chief Network Officer

Target Date: 8/7/95

Comments:  None

Proposed Revision:  None


Recommendation:
2.37 Develop an instrument, within existing automated systems (i.e., FMS), for the Outplacement Center managers to estimate and track costs for outplacement of staff, relocation expenses, employee pay and benefits consideration, counseling, training, etc.

Action Required:
2.37.1 track and monitor costs of outplacement

Action Office: Chief Financial Officer (17)

Comments:  None

Proposed Revision:  None


Recommendation:
2.38 Immediately appoint a multi-disciplinary Affiliation Task Force charged with reviewing issues identified in response to the draft discussion paper and developing plans for implementation of desired strategies.
 
Action Required:
2.38.1 appoint multi-disciplinary task force

Action Office: Under Secretary for Health (10)

Target Date: 12/1/95

Comments: Of the 28 comments we received on this recommendation, four comments supported Headquarters to manage the affiliations and educational opportunities; six comments recommended this task to the VISNs; and two comments felt the VA Medical Centers in a better position to manage the affiliations.  There were many concerned with this subject.  Specific comments are noted below.

Comments: AFFILIATIONS MANAGED AT HEADQUARTERS:  "VA is responsible under law for operating a national education program.  The proposed change would fragment that program into 22 different operations, and would have VA effectively abandon key national responsibilities."

Disapprove

Rationale: While this is true, a reorganization strategy might be developed that meets national goals and promotes local flexibility and needs.  The recommendation is to further review and address this issue.

Comments: "The Thibault Committee Report and the Vision for Change both identify research and academic affiliations as intertwined missions with a national policy, planning and execution focus."

Approve

Rationale: A special task force has been proposed to complete this work.

Comments: "It is our suggestion that any decentralization of this function receive a great deal of study and be researched thoroughly.  Perhaps the function would be best suited in the new VISN system under the direction of the Chief Network Officer."

Approve

Rationale: Study will be provided by the Task Force.

Comments: AFFILIATIONS MANAGED AT VISNs:  "Affiliation management I believe needs to be at the VISN Director level.  I simply do not see material value added to level and distribution of resident and house staff slots, at the national level."

Rationale: This issue will be addressed by the proposed task force.

Comments: "Oversight of the affiliation process at the VISN level would reduce duplication of paperwork for individual facilities who would be affiliating with the same schools.  It would also assist schools in placing students at the most appropriate training sites to meet the students' training goals and interests. ... If training positions and funding are decentralized, an effort must be made to maintain the integrity of the Social Work graduate training program."

Rationale: The same argument could be made for all health care disciplines.  The intent of decentralization of funding would be to allow the VISN the opportunity to determine it's specific training needs and earmark funding accordingly.  The issue will be referred to the proposed task force.

Comments: "Managing affiliations at the VISN level will allow a broad perspective of the needs and abilities of each VISN facility.  It will also take the pressure off the local facility when tough decisions need to be made."

Comments: 
"If indeed, our budget scenario is as predicted for the next seven years, support of education and research must be at the VISN level.  Otherwise, "carve outs" will be established and the core pool of money will be artificially eroded, much as it has been in the past."

"VISN offices should play a major role in fostering cooperation with medical school affiliates; such cooperative efforts would include education and research deemed essential to the VHA mission."

"Suggest a formal point-of-contact within VISNs or VSSC to coordinate interaction with research entities and facilitate access to data sources."

Rationale: Further study by Task Force.

Comments: AFFILIATIONS MANAGED AT VAMCs:  "Moving decision making regarding resident education and research to the VISN level carries sole risk.  There is the potential to undermine individual medical center relationships with their medical affiliates."

Rationale: Not necessarily so if structured correctly.

Comments: "I am concerned with the concept of the VISN Director being required to interpose that position between Deans and Department Chairmen of the professional schools and local VAMC management.  Relationships of this kind are built on ongoing day-to-day contacts between local VAMC management and Service Chiefs with the appropriate officials of the professional schools."

Rationale: The Work Group felt it important to further study the relationship between affiliations and their "local" counterparts in view of the need to coordinate activities on a VISN level.  The proposed task force would address this very issue in their deliberations.

Comments: Several comments were concerned about changing the management of affiliations and added comments such as:

"There is a discussion about Re-engineering VHA Education and Research Affiliation Agreement and placing them in the VISNs.  It seems to me that if this done it ought to be approached slowly and with caution.  ...  The ramifications and risks of undertaking such a huge re-engineering effort especially early in the life of VISNs seem considerable."

Approve

Rationale: To be considered by the Task Force.

Comments: "The plan puts full authority for decisions about how these training funds will be utilized on the VISN levels.  This could give powerful influential professions on the VISN level the opportunity to direct funds in their preferred directions.  The VA also need to plan on local facility and national level to meet future needs for health care experts."

"In spite of the fear of lack of oversight, to put a distance between the affiliate and VA executive will not solve any of the problems.  It will put good functioning, mutually beneficial affiliations at risk."

Approve

Rationale: The Work Group felt it important to further study the relationship between all types of affiliations and their "local" counterparts in view of the need to coordinate activities on a VISN level.  The proposed task force would address these very issues in their deliberations.

Comments: "There is concern that self-interest in larger VHA facilities within VISNs will result in bias in distribution of resources including FTEs.  There is also concern that the power and influence of local universities could be underestimated.  Local VHAs and Universities are not always "equal partners". The ability to recruit excellence faculties at VHAs has usually been a function of strength of affiliation agreements."

Rationale: Further study by Task Force will address these concerns.

Comments: "Need to define educational role of Headquarters and local facilities to avoid activities that may be counterproductive in the outcome of education and research and avoid curtailing freedom."

Approve

Rationale: This is in the Task Force charge.

Comments: "Professional and managerial training programs (for other than physicians and nurses) are not addressed in this report which could place associated health trainee leadership training programs at a significant disadvantage."

Approve

Rationale: Professional and managed training program were not our charge.

Comments: "I would question the need to appoint another group to study these issues at this time."

Disapprove

Rationale: Other groups have not addressed the affiliations in the context of VISN reorganization.  It requires special study that is not "hurried" and this is what is recommended.

Comments: "There should be an ability to disseminate stipends to the field for many programs, including Social Work."

Rationale: The proposed action would be to decentralize as much funding as possible from Academic Affairs to VISNs.  The issue will be referred to the proposed task force

Comments: "The Federal Advisory Committee Act requires Federal agencies to follow certain procedures in establishing and using advisory committees.  The report suggests establishing an Interdisciplinary Academic Advisory Committee consisting of VA employees, affiliated institution representatives, veterans service organizations, and others.  The Committee would provide guidance, counsel, and input for education and research activities.  The Committee would be subject to the Federal Advisory Committee Act.  We recommend that the report note the applicability of this law to this Committee."

Rationale:  Noted

Comments: "One suggestion that may be helpful for using this report most effectively would be to emphasize the need for inter-rather than multi-disciplinary since the two concepts carry important distinctions in terms of functioning."

Approve

Rationale: Substitute "inter" for "multi".

Comments: "It is suggested that the research strategy component be separated out and discussed explicitly."

Disapprove

Rationale: The Affiliation Task Force should have broad latitude to study this issue and make recommendations.  The affiliations are the underpinnings of our vision and mission.

Comments: "Recommend all sources of funding for education and training (i.e., RMECS, CEC, CHEPS, GRECCs,etc.) be shifted to a common budget."

"Tuition support funding should be expanded and made available to a wider range of candidates while flexibility is needed to move tuition reimbursement funding into tuition support.  Do not restrict the funding to only clinical employees and expand the categories beyond managed and primary care issues."

Disapprove

Rationale: Not in the perview of the Affiliations Group.

Comments: "I believe the VISN Activation report should focus on the patient care issues which will consume the VISN Directors and all of VHA in the next few years and not divert energy tilting at 'straw men.' "

Rationale: While patient care is indeed our reason for existence, change does not occur without "straw men" proposals to tease out key issues.

Proposed Revision: Change "multi" to "interdisciplinary".


Recommendation:
2.39 Charge VISNs upon their activation with enhancing education and research activities by:  (a).  Identifying mechanisms to become familiar with and track the wide range of academic activities within their facilities;  (b).  Designing methods to promote collaboration and partnership between affiliates, the VISN and individual clinical care facilities within the VISN;  (c).  Implementing education realignments and constructing new affiliation agreements that are outgrowths of clinical resource realignments within the VISN.  This should occur in consultation with Headquarters;  (d).  Developing strategies which encourage research activities, promoting growth and development and fostering cooperation and sharing; and  (e).  Developing approaches for Academic Health Centers and VISNs to jointly develop and integrate health delivery systems to maximize care for veterans and society.

Comments: All seven comments we received expressed concern regarding research.  Below are some of their comments:
"The concept of continuing a strong basic science component in our research program, with expanded activities in health services research directed at the care of veterans seems solid.  It is vital that centrally managed peer review be retained."

Approve

Rationale: Consistent with recommended actions.

Comments: "We want to strengthen our research mission through a variety of approaches--including more solicitations/requests for proposals.  Also we need to ensure appropriate feedback/communication links toward getting best practices research into health care practice.  And we need to publicize good research results as a PR initiative."

Approve

Rationale: The recommended action does not preclude this.

Comments: "Although affiliations are certainly germane to the VA research project, we believe that the relationship of the research program to affiliations is significantly different from the relationship of the education program to affiliations."

Rationale: Research issues do not have to be limited to this document.  It is not a position paper on research--but to ignore it in discussing affiliations would be wrong.

Comments: "Lumping of research and education 'VA's Academic Mission' is confusing and misleading, in that research has a broader purpose, including production of knowledge to help veteran patients and the veterans health care system."

Approve

Rationale: This could be better dealt with in the paper but does not change recommendations which are simply for VISNs to encourage research.

Comments: "The impact on mission changes will profoundly impact existing affiliations."

Approve

Comments: "Financial Management  --  Suggest adding, after last sentence, 'VISN Directors will pass through funding (and FTE) for research programs/projects approved in HQ to medical centers where funded investigators are located.'  VISNs are included in the funding channel to ensure that these organizational units are fully informed of all funding flowing into their areas of jurisdiction.  VISN Directors will responsible for ensuring a high quality research program."

Approve

Proposed Revision: No change is recommended at this time.












The following document contains comments not related to VISN Report Recommendations or Action Items


ATTACHMENT  2 



CATEGORY/COMMENTS/RATIONALE/PROPOSED ACTION:
Baldridge Criteria	
These comments apply to the VISN Activation Work Group, as well as the Performance Measurement Work Group and the Headquarters Restructuring Work Group.  In March of this year, the Under Secretary for Health spoke at length about the applicability of the Baldridge Management System to VHA.  The work group reports are consistent with the principles supporting the Baldridge system--but there are few references to the Baldridge.  A more explicit link between VHA restructuring and the Baldridge Management System would assist those individuals who will be challenged over the next year to operationalize the concepts in the work group reports.	
This comment relates specifically to the work of the performance measurement group.  Agree that Baldridge Criteria will continue to be useful in this regard.

Budget	
There are many financial systems issues and interfaces that must be addressed in order to activate VISNs.  It is essential that the VHA CFO coordinate these issues with the Office of Financial Management (047) at the earliest possible date to ensure that desired financial approaches for budgeting, accounting and reporting can be developed and assessed and if required, funds/resources can be identified where systems changes are required.  One example is the desire of VHA to provide budgets at the VISN level.  When the budget structure for the new VA-wide core accounting system, the Financial Management System (FMS), was developed sometime ago, VHA determined that the "station number" would be the primary budget level.  All FMS system controls, functionality, and reporting were developed and installed to accommodate budgeting at that level.  There are no other "budget levels" available in FMS to provide budgets at the VISN level.  Any changes to the way that FMS currently handles budgets would be significant and expensive.  It is possible for VISNs to be funded "on paper", similar to how regional offices are currently funded, however, the VISN director can only provide and record in FMS budgets that are given at the station/VAMC level.  The VISN funding level cannot be entered into FMS.  In order for a VISN to assess how it is spending against its budget, it will be required (as were the regional offices) to access data files within FMS in order to determine a roll up of the funds being expended at the station/VAMC level.	
Clearly these details need to be addressed during the implementation process.  The comment will be referred to the Allocation, Budgeting, and Business Planning Work Group.

Business Planning	
(1). One of the stated goals of the VISN structure is to interject efficiency and cost effectiveness considerations with the expected outcome to be an acceptable balance between cost and value (best value).  The VISN Activation report partially addresses this issue and the Allocation, Budgeting and Business Planning Work Group report proposes a capitation methodology, but the Headquarters Restructuring Work Group does not address this critical issue.  In order for the VISNs to address best value, Headquarters must structure itself to support the VISNs efforts.  For example, the VISN strategic plan and business plan must be integrated to produce a single cost effective strategic plan.  In order for the VISNs to accomplish this task in conjunction with Headquarters, Headquarters must apply the same best value criteria to areas such as strategic planning and budget formulation. (2). The Allocation, Budgeting, and Business Planning Work Group proposed capitation as the recommended method of budgeting and funding.  Capitation is probably the solution to long term budgeting and funding issues but in the short term VISNs are going to have to rely on the existing RPM system and the currently being developed DSS methodology.  Neither the VISN Activation or the Headquarters Work Group addressed cost comparison methodologies.  Cost comparison methodologies like DSS are an essential tool for the VISN to make comparisons and determinations on which facilities can provide required functions based on best value.  For a VISN Director to determine if a given clinical function should be provided by on VAMC or another or from an external provider instead of an internal provider best value comparisons based on accurate cost date is essential.	
These comments are specifically related to the Allocation, Budgeting and Business Planning Work Group and will be referred to them.

Business Planning	
The VISN Activation Work Group briefly addressed the new DSS costing methodology as a support system for Headquarters.  I feel that the DSS will be an extremely valuable tool for both Headquarters and VISNs in making best value decisions.
Agree.  

Cultural Change	
VISN Directors will need to address facility consolidations and mission changes.  They need to have support from HQ, especially when things get nasty.	
It would be important for such issues as mission changes and consolidations to be undertaken  with the full involvement of VISNs, the facilities involved and  Headquarters in a collaborative manner.

Culture Change	
In reviewing the workgroup's report, I find a number of issues that are of concern.  The basic premise that the VA must undertake a complete culture change is admirable.  The President of the United States signed an executive order in September 1993, that was intended to create a culture change of similar proportion by involving the front line work in all activities of mutual benefit.  To this end, Federal negotiating rules were changed to allow negotiations in areas that had, in the past, been exclusively management's rights.	
There is a recognized need to create the type of cultural change which would support Labor/management partnerships. 

Culture Change	
There has been no provision in this document or any of the other five that utilizes the experience and customer based knowledge of the front line worker.  References to employees are included as stakeholders without a vested interest in the processes and outcomes of customer service.	
See above comment

Culture Change	
Grouping employees with volunteers and trainees is belittling at best.  We have been told that we are full partners in government and this report shows that VA management still has a stovepipe mentality.  Believing that only management can make the correct decision or do the report in a timely manner.  VISN activation appears to be a good plan for a management team but leaves areas that had been important to the President and National Performance Review untouched.  Management layering is not mentioned in any report although RIF authority is.  It appears that the employees and their representatives are only to be manipulated and tolerated.  The goal of "employer of choice" can never be achieved without a culture change amongst upper management in the VA.  If the conceptual portion and application portion of this report are compared, it is very obvious that only lip service is being offered to labor.  VISN activation should include labor partners with management along with employee representatives meeting together in each VISN element to help the transition progress in a more informed manner.  There is the obvious need for facility Directors to meet.  It is also critical that labor representatives meet to assist in shifting of critical resources in each VISN element.	
See above comment

Culture Change	
As a patient advocate I agree with the statement that VHA must recognize it's social mission as well as it's medical mission.  Addressing our veterans' social problems and issues is not always a high priority but it should be if we are to change the social culture of many of our veterans in underserved special patient populations such as the homeless and chronically mentally ill.  Many of our special programs have long since established collaborative and partnership efforts with community organizations and health care alliances in order to expand social services to veterans.	
As pointed out in the report of the Work Group, the unique social mission of VA needs to be acknowledged and seen as a strength.

Culture Change	
Thank you for the opportunity to review the reorganization work group reports recently furnished to Committee staff.  While I believe we should not lightly intrude into internal VA organizational issues, I am concerned that certain proposals being advanced as part of the reorganization go too far.  While there is much to applaud in the VISN concept, this reorganization must not weaken VA as a national health care system or undermine VA's capacity to deal effectively with national issues.
Agree.  The reorganization effort is designed to strengthen and improve VHA's ability to deal with national issues.  The Headquarters restructuring effort needs to address the mechanisms for maintaining the "national" focus while supporting VISNs and decentralization. 
  
Culture Change	
Change in culture of work force in order to provide healthcare value to patients is best achieved by concentrating on the well being of each and every employee.  An employee who is wanted, respected and recognized will be courteous to other employees and to patients and customers.  Corporate cultural change cannot be dictated by rules, regulations, mandates or by education and training alone.  We must all be role models and set good examples. There is nothing like a happy, satisfied employee eager to come to work every day.  We must create the right ambiance for a positive cultural change.  Once the proper atmosphere is created the positive attitude and cheerfulness will spread throughout the system.  So let us first treat the employee like the way we are striving to treat our patients.  Automatically the employees will treat the patients well.  We can then achieve our vision of employer of choice and caregiver of choice by the single but neglected act of being nice to our employees.  Good behavior, happiness and cheerfulness are very infectious and will spread effortlessly.  Demanding good patient care from disgruntled employees does not work as we have experienced for so long.  So, here are the ingredients for being nice to our employees:  Recruit the best based not only on qualification, but also on attitude, behavior, and enthusiasm.  Treat all employees well and with equity and fairness.  The grade system must be improved, so that salary and benefits conform to the quality and productivity of each employee.  Mentoring and coaching should replace traditional supervision which is based on intimidation and harassment.  The proficiency and efficiency of all employees should be kept at cutting edge by providing appropriate opportunities for continuing education, training and staff development.  There should be individual development plans and career paths for all employees and appropriate career counseling so that every employee has the opportunity to develop to his or her full potential.  Performance evaluation should be faire, equitable and generous and monetary awards are again fairly given.  Each employee should have his health and personal life style changes, nutrition counseling, exercise, etc.  If we take good care of our employees, the patients will certainly benefit from that abundance of good feelings and goodwill.
Proposed Action:  Refer to Education and Training Work Group and include this information for VISN Directors in VISN Transition Resource Guide.

Culture Change	 
I believe going to an integrated health network makes sense in terms of coordination of care, elimination of duplication in the system, cost efficiency and competitiveness in the health care industry.  I believe it is the direction we need to be going.  The outlined structure appears to have the components to succeed.  My only concern would be that we don't become so focused on costs, efficiency and other administrative functions that the center of focus moves away from our primary purpose, "care of the veterans".  The other concern would be "How do we prevent competitiveness among the network medical centers and promote cooperativeness?
Proposed Action:  Include this information in the VISN Transition Resource Guide.

Culture Change	
This is an excellent well thought out piece of work.  I do, however, have two comments - a.  There is no question that "personal involvement, team development and consensus building" are critical requirements for the management team of VISNs, but these can be optimally utilized only if line authority of the VISN Director is clearly stated and then defined.  In reading this section I drew the conclusion, by inference, that line authority was intended but it sure wasn't emphasized.  I believe this is absolutely essential to effect the restructuring from a Hospital Based - Acute Care system to a true Health Care Delivery System.	The full intent of the Work Group was to assure that line authority was placed with the VISN Director.  
Proposed Action:  Orientation for VISN Directors should include the placement of line authority with the VISN Director and clear differentiation of "line and staff" relationships.

Culture Change	
References to behavior modification for employees and randomly assessing employees' understanding of VISN elements brings to light the fact that management has no intention of involving employees in the process.	
If this is the perception that comes through in the report, it needs to be changed.  Every attempt will be made to involve employees.

Culture Change	
The changes that will be required for the entire VISN plan to work will require a partnership of both labor and management.  A foundation of trust and respect will have to be created before any true change can occur.  If the managers designing this plan can convince the balance of the employees that there is a joint benefit anywhere other than just a job then the perspective will need a 180 degree change.	
See prior comment relating to labor/management partnerships.

Culture Change	
Partnerships with employees are the instruction given by the President of the United States.  All agencies must move toward this goal and to this it is important that the VA create a culture change along these lines before any hope of changing the way customer service has been delivered since the conception of the Department of Veterans Affairs.	
See prior comment relating to labor/management partnerships.

Eligibility	
A definable population which the VA will serve is really undefined; e.g., will it include spouses and family members of veterans, other non-veterans utilizing excess capacity.  What about eligibility reform and Medicaid waiver?
These issues will need to be addressed through eligibility reform.

EMPO	
In the "Draft Position Description: Director of a Veterans Integrated Service Network (VISN)" on page 93, second paragraph, modify the wording "and DOD contingency support" to read " and DOD contingency and emergency preparedness.
Agree.  Suggest report modification

Financial Manager	
As a Medical Center Impact is mandated as part of the VISN administrative team, will medical center CFOs and possibly Fiscal Officers still be required?
The VISN organizational structure should be determined by and within each VISN

HDQ -To be resolved
Under Clinical Program Management the function of clinical benchmarking is recommended to become a function of the VISN.  Clinical benchmarking is an area that needs considerable attention of VHA is to identify the "best in practice" and best in practice information needs to be systematically distributed throughout  the system.  It would seem worth considering, given the considerable work, time and effort that is entailed in any benchmarking study to consider that this be a function in the Office of Policy, Planning and Performance with considerable collaboration with the VISNs and Clinical Program Offices or at least these two offices be considered equal partners in these ventures.
Agree that clinical benchmarking is a valuable tool will require integration on a national level.  Comment will also be referred to Performance Management Work Group.

Headquarters	
Discussion (currently 1 paragraph) of VISN interaction with non-CNO offices at HQ (e.g., SHG Offices) needs more detail.  What does "staff relationship" to VISNs mean in practice?  Will there be no line authority for these HQ offices at all, even for Special Programs?  If not, in what way are "Special Programs" considered "special?	
See above comment

Headquarters	
A discipline specific presence in Headquarters on a clinical council could support VISN initiatives.  These could be under a staff relationship model.	
This comment needs clarification

Headquarters	
The current working relationship between Director, EMPO, and AsCMD for Operations will be continued between Chief, EMPO, and CNO for emergency medical preparedness activities.  Chief EMPO/CNO Interface - As the primary advisor to the Under Secretary for Health on emergency medical preparedness, the Chief, EMPO will maintain a close working relationship with the CNO to ensure emergency preparedness policies, plans, and resource obligations honor the "line-staff" relationship described in the report.	--

Information Management	
For VISN support, some functions can easily be shifted to IRM (e.g., security, office automation and telecommunications).  Management data analysis, corporate database support, or EIS development, however, cannot be reassigned or contracted out.  Over the years, region and Central Office staff have acquired the knowledge and skills that are unavailable elsewhere in VHA.	
It would be expected that the new structure would take advantage of existing expertise.

Information Management
Centralized data base access should be supported by MIRMO.	
This issue was referred to the Headquarters Restructuring Work Group.

Legislative Change
In general the work group is to be commended on the quality of the product which they produced and the consistency with the philosophy outlined in the Vision for Change document.  Of some concern are the assumptions outlined in Section III that serve as a foundation for development of the activation framework.  Some of these are, to a degree, presumptive of legislative changes that may or may not come about while others are vague, as "VISNs will not necessarily be bound by existing procedures an process.	
In order to provide some structure to the Work Groups, some general assumptions had to be made.  Certain legislative/regulatory changes are proposed.  Should they not be accomplished, other directions would have to be explored.

Mental Illness	
The Under Secretary's Special Committee for the Seriously Mentally Ill fully supports the transition to the VISN organizational structure.  However, the committee has deep concerns that the contemplated emphasis on a managed care delivery system will not well serve seriously mentally ill veterans.  Managed health care has made a practice of  excluding these patients.  We believe that services for the seriously mentally ill must be closely monitored during this transition to ensure that seriously mentally ill veterans are not denied the care they need.
Mental health programs are considered a special program component and are expected to be managed as such.

Nursing Role	
The undercurrent in the field is that of "Here we go again ... another VA reorganization."  The Vision for Change is a major undertaking, but outside of the beltway there is a wait-and-see attitude, considering the political dynamics in the capital city and the not-to-be-underestimated influence of medical school affiliates.  If changing the VA culture is to be accomplished, then the message must be in the presentation.  "Putting Veterans First" should visualize that care and cure go together.  This was exemplified by the recent presentation by Dr. Kizer and Dr. Valentine at the VAMC Madison, WI.  If this reorganization is to be viewed by the field as a new way of doing business, it requires the sustained presence of the principal physician and nurse working together as the primary interdisciplinary team.  To do otherwise, reduces this fine and needed initiative to "just another change."	
This information communicated to the group developing the VISN Transition Resource Guide.

Public Affairs	
The VISN Activation Work Group report does not specifically address how public affairs/communication issues and strategies will be addressed under the new organizational structure.  The current regions have some communication responsibilities, including coordinating consumer affairs activities, participating in special events and serving as communication liaison to Headquarters.  However, in my opinion, the communications role in the regions has never been fully maximized.  The reorganization, therefore, provides a perfect opportunity to ensure that a structure and process is put in place to ensure quality communications within the VISN and between the VISN and other entities, including stakeholders, Headquarters and other VISNs.  Clearly, there are two ways to address VISN communications:  hire a qualified, professional public relations practitioner in each VISN or tap the existing public affairs expertise within the medical facilities of the VISN.  The former, while in some ways the most desirable option, is perhaps unlikely given the small number of staff that will comprise each VISN office.  With that in mind, I submit a possible structure:  the senior Public Affairs Officer for the VISN and the Public Affairs Council.  In this scenario, one Public Affairs Officer in the existing medical centers of the VISN is identified as the most qualified to coordinate overall VISN activities as a collateral duty.  (This may include increasing their grade to reflect the additional duties).  This individual would be the contact for Headquarters and the conduit through which communication can flow.  This individual could serve as mentor and offer guidance to other facilities facing media issues, image problems or crisis situation, as well as supporting the VISN Director's specific communication needs.  This individual would also oversee a council representing all the VISN facilities.  These councils would meet periodically to discuss mutual problems, share successes and develop strategies to maximize VISN-wide communications.  The senior public affairs officers would not serve as a gatekeeper, but rather as a key contact point  with responsibility for ensuring two-way flow of communication.  I would be happy to meet with appropriate group members to discuss these ideas at greater length.	The report did not address this issue specifically.
Proposed Action:  Include this information in the VISN Transition Resource Guide.

Readjustment Counseling
Readjustment Counseling:  Do not see the need for a Readjustment Counseling Coordinator at each VISN.  Other special programs (like Blind) are not so represented.  Vet Center should be incorporated into medical centers as most Vietnam Vets are now being served in VA Medical Centers.	
The intent of the proposal was not to create new positions for readjustment counseling but to coordinate existing efforts with the new organization.

Readjustment Counseling
It is recommended that the requirement that "a readjustment counseling (vet center) coordinator position will be assigned to each VISN" be deleted.  There is not ample or sufficient justification for the establishment of 22 new coordinator positions specifically for vet center operations.  In light of Senator Cranston's charge to the GAO that readjustment counseling service be considered for absorption in the VAMCs, I would strongly suggest there is not need for such a position at each VISN office.	
See above comment

Readjustment Counseling
The statement that VISNs will not necessarily be bound by existing procedures or processes is at the crux of this reorganization.  Further explanation relating to issues such as Congressionally mandated programs, Civil Service regulations, union agreements and eligibility regulations is required.  Will the Readjustment Counseling Coordinator position assigned to each VISN be in addition to the 7 - 10 VISN FTE?  Is a full-time vet center coordinator necessary for each VISN?  p. 15 (VISNs) - Strong relationships must be established with states in which the VA will be managing care for Medicaid patients.	
See above comment

Readjustment Counseling
Through effective planning and design of the health care system, VISNs will ensure that VHA's specialized programs and expertise are preserved and strengthened.  p. 16, para. 3 (VISNs) - Each VlSN Director will report to the CNO and will be held accountable for meeting general and VISN-specific performance goals as specified in the performance contract.  p. 13, para. 2 (VISNs must assure maintenance of VHA special programs, including Spinal Cord Dysfunction.	
See above comment

Reorganization Process	
We have been undergoing reorganization for the past year.  We need to begin now, particularly as it relates to planning for implementation.  Reach out to your staff and use our expertise and talents to aid and help the transition process.  All the reports indicates a general time line, but implementation is not addressed.  The department has been through numerous reorganizations.  We have great ideas, but non-existent follow-through.  We are a football team that has  been in a huddle discussing play options, we have yet to play ball.
Noted

Reorganization Process
I appreciate the opportunity to comment on the Veterans Health Administration (VHA) reorganization transition work group reports.  I applaud the membership of each work group on an admirable overall effort to make recommendations on changing VHA into a more quality-conscious, patient-oriented health care system.  I do wish to express a few concerns regarding VHA's integration with department level processes, capital planning, information resources management, acquisition and material management, interim reorganization strategies, and the proposed structure of the VHA Headquarters.
Noted

Reorganization Process
Sound pre-planning and flexibility will facilitate an orderly transition seems to have been forgotten or put on hold.
Noted

Representation On Work Groups	
Why didn't any of the Regional QA Managers serve on these task groups; they may have had a different perspective?	
A wide variety of individuals from a diverse educational and experiential backgrounds were selected to participate on Work Groups.  No attempts was made to include every interest area.

Resources	
Modification to facilities as missions change will require additional resources. Given the current budget  forecast, we are concerned where the  resources will come to support these initiatives.	All needs will be identified and facilitated through the VISN planning process.

Resources	
Suggest eliminating phrase "all within available resources" because it does not add any specific meaning.	
Noted

Resources	
What will be the relationship between the VISN Director and the BDC?  Who will have ultimate authority over the RPM resource allocation process?
Comment referred to the resources work group.

Resources	
VHA may consider mirroring private sector practices with respect to capital expenditures.  I suggest that the VISN business plans could contain specific proposals to guide major capital acquisitions, and fund capital and operating expenses separately.  (2) The VHA Chief Information Officer (CIO) could relate and interact with VISN components more formally to plan, develop, and implement information infrastructure improvements.  In turn, I recommend that the VHA CIO work closely with the VA CFO/CIRO to integrate VISN information systems and telecommunications plans with department level priorities.  Also, VHA should consider developing detailed plans for adapting financial management systems to accommodate new cost centers as soon as possible.  This will enable the agency to have an early idea of the cost associated with the system changes.  (3) VHA should consider acquisitions as an integral contributor to the health administration's future.  Under a capitated payment system, VISNs will experience financial incentives to control costs and, therefore, monitor equipment expenditures.  VHA could review strategies such as national contracts, just-in-time delivery requirements, and product commitment and standardization.  In addition, VHA should consider the impact of any decentralization under the reorganization on acquisition and material management.  (4) Many of VHA's critical reorganization efforts such as eligibility reform and capitation rely on legislative action.  While VA and VHA wait for the legislative process to occur, VHA could develop interim strategies for accomplishing reorganization goals without legislation.
Agree.  These are all important issues which should be a part of the orientation program for new VISN Directors and VISN staff.

Rural Health	
Patients in rural areas do not have ready access to health care as their counter parts in the urban setting.  The institution of mobile clinics as support systems for the integrated model concept is an idea waiting to happen.	
The cost-effectiveness of operating mobile clinics needs further study.

Safety	
There is one issue which does not fit neatly into any single report, but which merits serious consideration.  Staff in the Occupational Safety and Health office noted that the report did not address ongoing safety and health responsibilities, and expressed concern about how this program will be managed in the new VHA.  I believe it is important to include safety and health roles as you continue to develop organizational plans, and understand that medical center personnel have provided comments on this issue that might be of interest.  With regard to further development of the VISN structure, OHRM staff would be pleased to work with VHA to help ensure appropriate economies of scale and avoid inequities and/or recruitment problems which could arise from establishing similar positions but dissimilar classifications in the new VISN offices.	
As region functions are evaluated this important issue will be carefully considered.  This issue will also be provided to VISN Directors as a part of their orientation.

Safety--Radiation	
The VHA Radiation Safety Program was established by the Chief Medical Director in response to repeated expressions of concern from the Nuclear Regulatory Commission (NRC) for improved and continued assurance of regulatory compliance and safety in the use of radioactive materials and to enhance the radiologic health of VHA patients and staff.  The program evolved to its present form with a National component to provide analyses and guidance and with the operational arms in each Region which provide oversight through workplace evaluation, problem identification and assistance with remedial actions.  The guidance and oversight functions together with a substantial regional and national training effort has produced dramatic and demonstrable results toward achieving the established goals, especially reduction of NRC violations.  Additionally, findings of IG facility audits has required extension of the efforts to matters of x-ray uses, safety and training.  A natural extension of this work has been continued evaluation of means to effect economies and efficiencies from the huge scale of NRC licensed clinical and research activities in VHA  To this end a FY97 initiative was submitted to consolidate the 290 clinical and 1200 research programs under a single VHA "Master" license rather that the plethora of individual licenses that currently exist.  Several advantages accrue from this strategy:  efficient, simplified licensing, intra-mural oversight, national accountability, minimal facility interaction with regulators, responsiveness to facility needs, reduced adverse PR exposure, small incremental costs and annual cost savings of about $1.2 M.  We are asking that your Workgroup evaluate this initiative together with the recommended actions.  The proposal is consistent with and can be accomplished through the VHA reorganization.  The necessary implementation strategy is aided by the already decentralized structure.  We strongly believe that the organization of this program, if favorably considered, should remain decentralized and be responsible to a national professional services office.  The customers for the product are nuclear, radiologic and research professionals where the requisite knowledge base resides.	
See above comment

Safety--Radiation	
This pertains to radiation safety under the VHA reorganization.  A new initiative, recently submitted to VACO, which should be addressed is the proposed formation of a VHA Master License (ML) which will consolidate all the individual hospital NRC licenses.  This will result in a cost savings of approx. $1 million/annum.  Among other tangible benefits of this proposed action, which have been realized by the Air Force and Navy, will include more insulation of the individual hospitals against adverse actions of the NRC and greater consistency of radiation safety programs.  This proposed action has been endorsed by NAGORS (National Advisory Group on Radiation Safety).  In order to gain approval of the ML, a VHA radiation safety committee, chaired by the USH or DUSH, and a licensing and inspection mechanism must be designated, since the overall oversight of the licensees by the NRC would be assumed the VHA under the aegis of the Master License.  Currently the VHA level radiation safety oversight is carried out by 1 VACO level and 4 Regional Office professionals.  It would appear that these positions and the additional 2 FTE proposed must be aligned centrally and dispersed geographically to satisfy the NRC as well as carry out policy and inspection mandated by the NRC.  Additionally, the establishment of a unified radiation safety program vis-a-vis the VHA ML would provide a framework for further developments which will benefit the agency as a whole, e.g. establishment of a cohesive x-ray radiation safety program which does not exist at present.	
See above comment

Safety--RSFPE
The Regional Safety and Fire Protection Engineers are a very valuable resource to CM and the resident engineers out on construction projects.  This function should continue to exist.  These engineers network with federal organizations such as the Environmental Protection Agency (EPA), National Fire Protection Agency (NFPA), and the Occupational Safety and Health Administration (OSHA) that develop laws to regulate environmental protection and safety.  In addition, they assist the medical centers in complying with these statutory requirements.	
See above comment

Safety--RSFPE	
Add conducting JCAHO Statement of Conditions as a function of RSFPEs.  This responsibility became effective in 1995 when the JCAHO standards for PTSM were replaced with the Environment of Care standards.	
See above comment

Safety--RSFPE	
Regional Safety and Fire Protection Function  It is critical that the functions performed by the current VHA Regional Safety and Fire Protection Engineers remain at full support, either at VISN Support Service Centers or at a medical center.  One of the most important functions they perform is the plan review of medical center construction projects and leasing activities for building and fire code compliance and JCAHO (Joint Commission on Accreditation of Healthcare Organizations) accreditation.  The medical centers do not have the in-depth knowledge and resources to assure this compliance on their construction projects.  VA acts as it's own building and fire code official.  VA can not just submit plans to local authorities because (1) local authorities do not have legal jurisdiction and (2) VA must follow national consensus building and fire codes per Public Law 100-678 and for JCAHO accreditation purposes in lieu of following local building and fire codes.  Even though there may be a reduction in VA's major construction projects in the coming years, the medical centers (and VISNs) will still have substantial NRM and minor construction projects and leasing activities.  VHA Fire Department Oversight Function  It is imperative that this function be accounted for at a VISN Support Service Center.  Currently, this oversight is provided by a Central Region employee who is located at the Des Moines, IA Medical Center.  This centralized function is placed in the field but overall policy direction is provided by VHA Central Office (138C3).  This individual was made responsible for the overall VHA coordination of the operational and closure issues involving fire departments due to his knowledge and expertise.  Because of the focus placed on contracting out and closure of fire departments, failure to support this function could present a serious risk to patients and employees and cause union and public affair problems.  Currently VHA has 32 medical centers with in-house fire departments throughout the current 4 regions.	The report did not specifically address where these functions would occur. 
Proposed Action:  This information should be provided to the group evaluating current region functions to determine appropriate placement in the new organization.

Special Programs	
I totally agree with the first sentence in this section (bottom of Draft page 13).  VISNs "must" assure maintenance of VHA special programs!  p. 93 (Appendix 9) - While the preceding Roles and Responsibilities identify the importance and unique nature of VHA special programs, there appears to be no accountability for such program maintenance reflected in the VISN Director's position description.  Without the inclusion of VHA special programs maintenance accountability in the official position description, I sense that the importance of these programs will be diminished.
Every intent is to maintain and strengthen VA's special programs.  Special Program offices will be continued and be  responsible for developing national policy and guidance which will be conveyed to the CNO who will ensure that appropriate performance criteria will be incorporated into VISN requirements.

Special Programs	
Issue of Special Program management is a key point and requires more detail.  Relationship between HQ and VISNs, in terms of their roles/responsibilities with Special Programs, needs to be fully described.
See above comment

Special Programs
Discussion of Special Program management (currently 1 sentence) needs more details regarding roles/responsibilities of HQ (particularly SHG Offices) and VISN.	
See above comment

Special Programs
Definition of VHA Special Programs is not accurate for all Special Programs.  Not all "address service-connected illnesses highly specific to the veteran population" (e.g., Homeless, GRECCs).  Should list other criteria used in Vision for Change to define Special Programs, i.e., services that are unlikely to be adequately serviced by a market-driven system and ones for which VHA has developed unique expertise and resources.	
See above comment

Special Programs
This Work Group had what would be considered the most difficult task of all the Work Groups.  On one hand, the report strongly supports decentralization and the VISN structure, i.e., VISN Directors and the Chief Network Officer must have maximum flexibility in determining their specific organization structure and staffing requirements, no two VISNs will be exactly alike, VISNs need a high degree of flexibility, VISNs should not be bound by existing procedures or processes, and centralized control of training resources to the VISN level.  On the other hand, it recognizes that the VISN must assure maintenance of VA's Special Programs and included a requirement in the position description of the Clinical Services Manager concerning maintaining these Special Programs and communication with Special Programs staff.  However, the report also emphasized the "staff" relationship of Headquarters Program employees.  Given the organizational changes that have been proposed by some VAMC Directors and those implemented by others, e.g., placing Prosthetics under an Administrator for Resources at VAMC Iowa City, placing Prosthetics Purchasing Agents under Supply at Denver, etc., and the maximum flexibility advocated VISN Directors in this report, the organizational future of Prosthetic and Sensory Aids Service (PSAS) in the field is in doubt as is the provision of uniform prosthetic services and related benefits.  For all practical purposes, Prosthetics Improvement Implementation Plan (PIIP) Objectives 2 and 3 concerning PSAS organization in the field and PIIP Objective 11 concerning training of PSAS staff would be eliminated.	
See above comment

Special Programs
Because the Blind Rehabilitation inpatient program is not considered "cost effective," if it is incorporated into a capitated rate system, will this ultimately lead to the Blind Rehab Centers competing among themselves?	
This comment is referred to the Resources Work Group

Special Programs
A recommendation has been made to develop joint ventures with private health care providers to expand services and markets, and to have veterans receive their health care from non VA contract providers.  Is it possible that blind rehabilitation services could be contracted out?  If this is so, it needs to be carefully reviewed, since there are very limited areas where contracting could be utilized.  Private sector blind rehabilitation services in no way compare the quality VA inpatient blind rehabilitation program.  Since every VISN will not have an inpatient Blind Rehabilitation program what is the incentive to send veterans to the program.
Clearly the writer brings up a good point. However, due to differences within each VISN health care market, contracting should be addressed on a case-by-case basis.  This concern will be referred for inclusion in the orientation for new VISN Directors. 

Special Programs
SEE ENTIRE PVA LETTER
The issues identified all are of concern and should be addressed through the Executive Correspondence process, by the Coordinating Committee and by the VISN Director orientation .  

Timeframes	
Unrealistic expectations of time.
Admittedly timeframes are tight but given the need to expedite the change process in light of the current health care market and governmental realities, time is of the essence. 

Transition Process
This is an extremely well thought analysis and set of recommendations about the most central and the most difficult to achieve piece of the transition plan.  I believe the recommendations proposed represent the best approach to the problem.
Noted

VISN Director Selection
VISN Directors hired within VA should not be permitted to manage within the VISN they currently are located (if they are part of the triad).  Although one may argue that such an individual knows a good deal about one or more facilities in his or her area, fresh leadership will be needed in order to avoid being "too close to the forest to see the trees" and to forge collegial relationships among facility directors.
Noted.  This will be a decision of the selecting officials.

VISN Support	
Specifics as to resource support for VISN activation is vague.  The host VISN will provide administrative support to the VSSC"; will additional FTE be available above the VISN specified level of 7 - 10?  p. 65 - 78 (Action Plan) - The Action Plan talk to either lease or renovation for VISN office as well as distribution of funds for equipment, furnishings ... etc.  There is no mention of what resources will be available for these activities, what methodology would be used in determination of the resources and what if any caps may apply to the establishment of a VISN office.	
The report does not specifically address the type of resource issues identified.  Some of these were addressed broadly in Vision For Change.  
Medical Centers co-located in cities where current Regional Offices exist  have already been provided with support staffing.  It is not expected that VSSC staffing support required will exceed that of Regions.  The VISN complement of 7-10 FTEE should not create undue hardship on Medical Centers providing support.  

VSSC	
With reference to the Contract Service Center (CSC), it should be noted that the CSC pilot program is currently underway and did not adversely impact employees at nearby facilities.  VISNs may find a surplus of technical staff performing similar functions at the healthcare facilities and the CSC.  As a result, there should be a clear delineation made between CSC functions and Acquisition and Materiel Management Service personnel at the local VA healthcare facility.	
This issue should be addressed within each VISN.

Women Veterans	
Regional Women Veterans Coordinators (WVCs) are mandated by P.L. 102-585.  They have been essential to the progress of the Women Veterans Health Program, which has special program status in the reorganization plan.  The positions were centrally funded in 1993 and 1994, although travel and other funding required to carry out their responsibilities has been provided by the Region.  This has the appearance of layering although the real authority always rested with the Regional Director.  The VACO Women Veterans Health Program interacted with the Regional WVCs in a staff role, sharing the interpreting policy guidance and planning and executing educational and training activities and materials.  While many of these functions could be centrally located, the continuing construction of MAMOE makes this unrealistic.  Since they are part of a special program for which performance measures are being developed for the VISNs and VAMCs, some of their function probably should be retained at the VISN level, where the small staff would dictate that this would be a collateral duty.  My personal preference is to retain their function in a support role, with each Regional WVC having responsibility for a number of VISNs in the same way the CNO's teams would do.  They could be physically located in the VSSC and should be considered for one of the core functions covered by consultation and data management analysis when the details of that structure are taken up by the Board of Directors.
The report did not specifically address where these functions would occur. 
Proposed Action:  This information should be provided to the group evaluating current region functions to determine appropriate placement in the new organization.
VISN Activation Work Group Decision Document