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

INTRODUCTION
General Comments:  The New  Organizational Structure 
  Several observations (5) were made regarding the new organization bearing a close resemblance to the former one.   Comments (4) emphasized that the organizational chart looks like the old one, and depicts VHA as a traditional hierarchy with lines of authority denoting the offices with greater influence and administrative priority.   Even accepting that reengineering relies more on redefining responsibilities and functions of offices and reshaping the relationships among operations, it appears that VHA is retaining the old structure and misplacing offices within the new hierarchy.  This comment and others (7) expressed concern  regarding the size and placement of functions, and concern that the new HQ organization having little or no relationship to the VISNs and field organization.  
 Realizing the challenge associated with critical reductions in operating budgets in the field for the years ahead, several writers (5) expected a concomitant downsizing or flattening of HQ to reflect the realities of the new organization.  One writer emphasized that it would have been helpful to understand the budgetary implication on any proposed changes and realignment of dollars that will occur. 
 One VAMC director also emphasized that a flattening of the HQ organization would speed up decision making for the field and shorten the concurrence chain.   Several writers (3)  noted that the proposed movement of positions and functions horizontally within HQ does not clearly support decentralization of authority to operating level (VISNs).  One commentary also emphasized that neither does it clearly support the key principles of the National Performance Review (i.e., cutting red tape and micro-management and empowering employees to get results by delegating authority and responsibility).

Rationale:   The intent of the Headquarters Restructuring Workgroup was to develop an organizational structure reflecting the Vision for Change document that does change program elements such as the Office of Policy, Planning, and Performance (PPP), the Chief Information Officer, and the Product Lines/Strategic Healthcare Groups operation within the Office of Paitent Care Services.  Whether employees are placed in boxes or circles or shown in straight lines, there is a requirement for some organizational structure.  

The new organzational structure proposes a role of HQ to provide staff support to the field, to the VISNs, to the Secretary, and to external groups through an integrated, interdisciplinary model. 

The charge to the workgroup was not to reduce staff nor did it include costing of various scenarios.  The 1996 Budget constraint has impacted realignment, but it was not a known factor or an ascribed assumption of this group's work efforts and deliberations.

Comments:  Concern that current HQ FTE is only being rearranged, and there is no move to critically review HQ or  its out placed field units for reduction
 Commentaries (15) wholeheartedly agreed with and offered numerous laudable statements regarding the workgroups focus at HQ integration , streamlining and process reengineering, noting that the initial efforts of the HQ Restructuring Group were straight-forward and revealed a significant amount of work.  
 However,  several observations (8) were made that no major reductions in FTE or tasks were evidenced.   Rather than eliminating offices or functions,  the report retains many  HQ offices with similar and/or related activities that add to the fragmentation and duplication of effort. 
 Several writers (3)  questioned the value or assignment of many out placed field units being denoted as HQ support, such as CMOPs.   One writer specifically indicated that only  the out placed field units associated with the Office of Policy, Planning, and Performance were identified within the workgroup report, and questioned why only these HQ support units were singled out for scrutiny and review when considerably larger offices with extensive field components were not addressed.   It was emphasized that all HQ organizations FTE levels should be examined well before January 1996. 
 One writer commented that the National Media Development Centers, Regional Medical Education Centers and other Academic Affairs field units need to be added to the list of out placed units supporting HQ.

Rationale: Commentary is consistent with many of the Workgroup deliberations and discussions.

Comments: Need for Continued Review and/or Study by Additional Workgroups
 Several individuals  (5) commented on the intricacy and complexity of the HQ organization, and the lack of definition of many of the recommendations and action items.  Although many writers supported and encouraged additional task forces and committees to study the areas suggested in the report, an equal number of commentaries emphasized the need to eliminate or restrict ongoing committee work.   Several writers (4) strongly  emphasized that recommendations should be implemented with course corrections as needed being identified and acted upon as the new organization evolves.   One VAMC Director also emphasized that it is important that those persons assigned responsibility for major HQ elements have the latitude and flexibility to alter the evolving structure as necessary.

Rationale: Commentary is consistent with many of the Workgroup deliberations and discussions.

Comments: Composition of Workgroups and/or Task Forces when these groups are suggested to evaluate a Program and it future organization
  Several writers (4) commented on the wisdom of assigning Program Directors (i.e., Chiefs of Programs) to evaluate the need to continue the program and or determine staffing for a program for which they have major responsibility.  It was emphasized that these individuals have the most to lose (or win) to the evaluations of these programs and proposals.  Thereby, the outcomes if favorable to the Chief might be questioned as 'empire building' or at least viewed as not an objective analysis.  Thus, the use of an impartial individual and/or organizational entity  that did not have a stake in the outcome was suggested when further program evaluation  or assessment was  recommended.

Rationale: The Workgroup agreed with this concern, and strongly believed that 'user' input on how HQ is restructured should emphasize the new culture of HQ as support to the field.  Adjustments in the report  have been made to recommended task force composition to assure field representation at the level of VISN or VAMC directors, as appropriate.

Comments: Review and/or Incorporation of Comments Received in Response to Dissemination of Draft Report
 Several writers (4) expressed concern that their comments made during interviews of Program Officials and/or submitted in response to the dissemination of the draft report did not result in a change in the information or recommendations in this report.  Additionally writers were uncertain if their commentary had been taken into consideration during the deliberative process of the workgroup since the final report did not discuss or reflect the issue,  suggestions, or concern raised in their response.
 One writer, who also participated as a subgroup member, expressed astonishment that the final report reflected an issue that was neither an issue in the Subcommittee nor in Core committee discussions in which she participated.  This writer expressed concern that the report presented a minority opinion of the core committee.

Rationale: The HQ Restructuring Workgroup met as a core group prior to the final report.  All comments received were reviewed in detail by the appropriate subgroups and taken into consideration.

Comments: Implementation Planning and Timing of Actions
 Several writers (5) commented on the importance of beginning implementation planning immediately.  Concern was expressed that the October 1 beginning dates were, in many actions, too late to begin important phases of the implementation activity.  Other observations were made regarding the ability of the various organizational entities to meet the target dates given the complexity of the issues presented.   Several writers (7) recommended the critical  review of action dates because they were either insufficient to allow appropriate opportunity for review of an issue, or not immediate enough to assure aggressive implementation activity resulting in significant change in HQ.  
 Concern was expressed regarding the impact of FY 96 MAMOE appropriation action and impact of FY 97 implications.  This writer recommended that several exhibits be prepared to help the USH use the reorganization to minimize the operational impact of any staff reductions.  These exhibits would assist decision making on the relative sizes of the components of the restructured HQ consistent with budgeted levels.  The approved allocations could be shared with HQ Committee and subcommittees to expand their reports to suggest how targeted levels should be achieved.  The reorganization and staff reductions should be treated as a unit conceptually even if implementation cannot be simultaneous for practical considerations. 
 Comments (3) suggested that the report document more sharply compare and contrast functionally how the proposed new organizational structure will differ from the current.  A comprehensive chart listing organizational elements/functions (HQ)/FTE and current assignment, with proposed disposition (i.e., VISNs, VAMCs, HQ location) and projected assigned FTE, would provide a summary and bottom-line.   

Rationale: Commentary is consistent with workgroup deliberations.  As appropriate, recommended implementation dates have been reviewed and revised.   It is emphasized that dates and/or methods of implementation will be determined and correlate with approval and/or concurrence of recommended actions, if received, by the Under Secretary for Health.

The charge to the workgroup was not to reduce staff nor did it include costing of various scenarios.  The 1996 Budget constraint has impacted realignment, but it was not a known factor or an ascribed assumption of this group's work efforts and deliberations.	

Comments: Report Context
 Several commentaries (3) noted that the use of abbreviations in the report is extensive, making the document somewhat challenging to read for an individual not familiar with the terms.  The addition of a glossary of terms was requested.
 One writer points out that there are references in the report to a questionnaire which was utilized.  However, there is no indication as to who these went to, what they were about, and what were the outcomes?

Rationale: Throughout the Decision Document the use of abbreviations has been limited.
 The questionnaire referenced was utilized by the Healthcare Programs subgroup to obtain information from program officials in Clinical Affairs as part of the interview process described within the report.

Comments: Organization of Acknowledgments and Membership of Subgroups
 One writer commented that the listing of participants in the HQ Restructuring Workgroup and its subgroups did not accurately  represent the membership or participative integration of the subgroups to the core group.  Although the membership of each subgroup was provided, the listing did not indicate the chairs or members of each subgroup who also served as members of the core group.
 Another writer noted that the titles for two individuals listed as members of the workgroup was listed incorrectly. 

Rationale:  The subgroups referenced within this section of the report were chaired by members of the core HQ Restructuring Workgroup as follows:
 (1) Robert Frymier, MD, chaired the Subgroup for the Office of the Under Secretary for Health and Policy, Planning and Performance; (2) Ronald Gebhart, MD,
chaired the Subgroup for Healthcare Programs; (3) Smith Jenkins chaired the Subgroup for Support Programs; and (4) Thomas Hogan chaired the Subgroup for Infrastructure.


OFFICE OF THE UNDER SECRETARY FOR HEALTH (USH) - Recommendations 1.1 through 1.13

Comments: Concern was expressed regarding the new structure and reorganization plan.   It was emphasized that the diverse functions of the Office of Policy, Planning, and Performance cut across many apparent needs of the system.  This writer pointed out the VHA charges of patient care, professional education and research, and noted that the policy  issues, strategic plans, analysis and performance measures are directed to these charges.   The writer recommended a more functional organization in which the DUSH has a chief of each of these areas in his immediate office.  Each chief with offices of planners, performance measures, analyses and policy would be focused on the charge given that particular chief.

Disapprove

Rationale: Availability of services addressed in new organizations.

Comments: One physician emphasizes that the difficulties of reporting are clearly identified in the Issue Statement related to the Office of the Under Secretary for Health.  Yet, concern is expressed that the method for solving this issue is not clearly addressed in the remainder of the proposal and several points of communication between the VISN and headquarters would seem possible and may represent the most efficient operating model.

Rationale: Noted an an issue to be addressed as the new  organization evolves.

Comments: One writer noted that the HQ report identifies as an issue the need to establish a well understood process for decision making.  This individual expresses concern that the report recommendations describe the need to define the various roles of USH, DUSH, and the CNO, but notes that the report does not propose a structure to facilitate policy issue discussion and decisions.  An option suggested is the establishment of a formal policy board that meets routinely to discuss issues of  significance.  The writer emphasizes that establishing a board with prescribed formats for written statements and analysis to be presented before the board and with prescribed formal vehicles for recording and promulgating the decsions would go far in structuring decisions and discusssions necessary in the day to day operations of VHA.

Rationale: This recommendation supports the need for specifically delineating the roles and responsibilities of the Office of the USH.   Although not a specific recommendation of this workgroup,  this commentary is noted as a viable suggestion for consideration by the DUSH or CNO as the new organization evolves.

Comments: The Director, National Veterans Service of the VFW notes that it appears that physician peer review is centralized as opposed to leaving it up to the field to conduct this activity.  He expresses concern that this seems to be in contravention to the intention to decentralize the management function of VHA.

Rationale: Commentary unclear.

Comments: The Director, National Veterans Service for VFW expressed concern that there is no mention of interaction with veterans service organizations within the workgroup report.  The VFW considers it essential that there be an individual or office specifically designated to serve as liaison between the USH and the VSOs.

Rationale: This is addressed within the Office of the Under Secretary for Health as part of the functions aligned under the Chief of Staff.  No changes have been made to information noted in Vision for Change.


Recommendation:
1.1 The Chief of Staff should continue integrating all the internal functions of the Office into a smooth, well-understood process.  Due to the number of staff in of Office of the USH and because of the high volume of issues to be addressed in the transition, it may be helpful to detail someone to the Office of the USH for 60 days to observe and make recommendations on how to set up the internal office procedures to accommodate the needs of the new VHA organization and the operating styles of the new leadership.  This individual can be assigned from within VHA or a consultant hired.

Action Required:  
1.1.1 Either through a detail or use of a consultant, review the internal operating procedures of the Office of the USH and recommend further refinements to the COS.

Action Office: Chief of Staff

Target Date: NTE 12/1/95

Comments: One writer expressed concern with using the term at the HQ level  stating that the term "Chief of Staff" has traditionally been associated with a clinical position both at the VAMCs and in the Regions.   He recommended the use of other titles that might be considered are "Assistant Chief Administrative Officer, Deputy Under Secretary, etc."

Disapprove

Rationale:  The use of the Chief of Staff title is very common among bureaurcacy, and in the VHA is patterned to mirror the use of the title at the VA level for a position with similar functions.	

Proposed Revision
1.0.1 Addition Other Technology assessment (high cost/high tech equipment, procedures, and pharmaceuticals) is currently fragmented and dealt with by a number of elements within VHA.   Technology assessment  affects hundreds of millions of dollars in expenditures, and the matter of where this program belongs should be determined.  A process for the ongoing management of this matter should be determined at the National level.  It is recommended that the DUSH convene a multidisciplinary task forced chaired by the COS, with participation of the CFO, CIO, Director R&D, Chief PCS Officer and field representation, to review this issue.   A review should includes the scope of this matter and a recommendation for assignment of this function.  (See Healthcare Programs, General Comments).

Action Office: Office of USH, Chief of Staff

Target Date: Completion of review NTE January 12, 1996

Recommendation:  
1.2. In the Vision for Change, it is recommended that this function be realigned from the Chief Financial Officer (CFO) to the Chief of Staff.  After review, however, it is recommended that the function of Office of Inspector General (OIG) and General Accounting Office (GAO) Liaison should be placed within the Office of Policy, Planning, and Performance (PPP) because the function needs to be coordinated with other performance measurement activities and with the Medical Inspector (MI) function.

Action Required:  
1.2.1 Realign the OIG/GAO liaison function from its current organizational location in the Office of the CFO to the Office of Policy, Planning, and Performance  (See also actions 1.12 and 1.45.2 )

Action Office: Office of USH

Target Date: 10/1/95

Comments One writer expressed reservation regarding this realignment of the OIG/GAO report coordination function into PPP.  This writer believes that the imposition of layers away from the key decision makers has created unnecessary gaps and lags in communication.  It was also noted that the OIG/GAO should not report to the Chief of Staff as suggested in the Vision for Change, as OIG/GAO needs immediate access to the DUSH who has been the key official meeting with OIG and GAO concerning VHA official positions.  The writer did concede that if the Under Secretarys office, including PPP, operates in a non-hierachical fashion, placement in PPP will not be problemmatic.

Disapprove

Rationale: Placement of this function within the Office of PPP does not preclude access to the Deputy Under Secretary for Health as required to deal with issues requiring immediate attention.

Comments The Deputy Asst Secretary for Financial Mgt does not support the realignment of this function from the CFO organization, emphasizing the focus on performance measurement.  The varied audit related activities coordinated and/or conducted by the CFO are cited in support of the CFO as the organization with the best knowledge to respond to IG and GAO audits.

Disapprove

Rationale: The OIG/GAO function is not limited to the handling of financial audit related issues, and includes other clinical and administrative topics that cut broadly across our healthcare system.  A majority of these issues require coordination with the Office of Healthcare Inspections and the Medical Inspector.  Placement within the Office of PPP provides for the optimal use of system wide performance measures as well to identify problems,  activity trends, and monitor improvements.  The expertise of individuals in the CFO will also continue to be available from staff as needed.

Recommendation:
1.3 The Legislative Affairs function is also recommended to be placed within the Office of PPP for coordination with overall policy and planning activities.

Action Office: Office of USH

Target Date: 10/1/95

Action Required :  Move the Legislative Affairs function from its current organizational location to the Office of Policy, Planning, and Performance.

Comments The Director, National Veterans Service of the VFW commented as follows, "Although we are uncertain, it would appear the plan diminishes the legislative liaison capability of the VHA."

Diapprove

Rationale: Placement of the Liaison function in this Office does not diminish this capability.

Comments: One writer comments that the proposed placement of the legislative function within the policy office of PPP appears to be sound.  This writer notes that the report itself is silent on the need to rethink the legislative function as it currently exists within VHA.  The writer suggests that rather than simply transfer an existing function and staff to the Office of PPP, a new prospective legislative activity needs to be designed and implemented.  This writer adds that VHA needs to have a prospective activity that ties its strategy, priorities and operations to an assessment of legislative changes that may be needed to reach its objectives.

Rationale: Commentary is not inconsistent with report, and no change in action is required.  New  Chief of PPP can consider suggestions for assessment of functions of this program after entry on duty.

Recommendation:
1.4 Establish an Office of Employee Education aligned within the Office of the USH, and also create the position of the Chief Employee Education Officer reporting to the Deputy Under Secretary for Health (DUSH).  This office will be field based, working with the VISNs, with a small staff component in HQ.  The primary functions of this office will include:  the creation of a learning organization; the design of learning experiences for the work force to achieve the required cultural change and meet the education needs advanced by the Education and Training Workgroup; and the restructuring and integration of the existing VHA employee education network to maximize quality, efficiency, and cost effectiveness.

Action Required: 
1.4.1* Establish an Office of Employee Education.
1.4.2* Establish a search process to select the Chief Employee Education Officer.

Action Office: Office of USH

Target Date: 8/1/95

Comment:  1.4.1  Several  requests (7)  for further clarification of this office, particularly regarding its relationship and/or link to and impact upon the proposed VA Learning University.  Also information was requested on the impact upon the RMECs and tuition support programs.

Rationale:  The VA Learning University (VALU) has not been committed to as yet.   At time of approval, these issues will be worked through by the Chief Employee Education Officer.

Comment:  1.4.1  Writer supports employee education, concurring with an agency wide, systematic approach to management development, fiscal, A&MM, and other 'core' training needs.   It is envisioned, however, that the VISN and facility directors will develop employee specific needs training.  The writer further recommends that VISN directors buy training needs from the RMECs aligned under the Office of Employee Education. 

Approve

Rationale:  The workgroup agrees that this is a function consistent with the position of the new  Chief Employee Education Officer.   This type of matter should be explored by the incumbent of this new  position. 

Comment:  1.4  The Director Education & Trng Ctr for Engineering & Construction Mgt. supports the consolidation of education units to allow the most efficient meeting of national training needs.  He emphasizes that every effort should be made to assign all of the training functions that impact VHA to this office in order to assure efficient coordination.  One function which he notes that is not being realigned is VHA police training.  One possible negative impact of realignment would be if sufficient resources are not available to meet requirements.  He also emphasizes that training needs that impact the entire VA system would be inefficient to be developed at the VISN level because of the reorganization and a necessity for cultural change training.  He recommends that the Chief for this office be appointed ASAP to provide leadership to the education network and establish training priorities.  (See also commentary for 1.36).	   

Approve

Rationale:  This commentary is consistent with the report, and the workgroup agrees with the premise of relignment of all employee education functions.  Police training can be explored for inclusion by the new Chief Employee Education Officer.

Comments;  1.4  One VAMC Director supported consolidation stating it makes sense to have all education under one office.  He emphasized, however, that there needs to be safeguards to ensure the administrative training resources are not gobbled up by clinical needs.		

Rationale:  Noted.

Comment:  1.4.2  One writer recommended that the Chief Employee Education Officer position should be retained as a HQ position with a strong staff component.  She emphasized that the existing education network is field based with no dedicated HQ leadership position resulting in the fragmented system criticized in the Morevec Report.  She questioned the disconnect of elevating employee education to the Office of the USH only to decentralize authority and accountability to the field?	  

Approve

Rationale:  Upon review, the current recommendation does require clarification.  A revision of recommendation 1.4 is provided below.

Comment:  1.4.1  The Chair of the Employee Education Network supports the creation of Office of Employee Education and the establishment of the  position of the Chief Employee Education Officer reporting to the DUSH.  He recommends the immediate appointment of an interim director to coordinate the transition efforts.  He also emphasizes that the functions of this office are critical to the Transition and require prompt attention.  Thus, the Office should be established as soon as possible. 	  

Approve

Rationale:  Commentary is consistent with our report.  Appointment of Chief Employee Education Officer has been recommended to be effected ASAP.  No interim position is under consideration.

Comment:  1.4  One writer comments that 'the creation of a learning organization' as a function of the new employee education office appears to be more of a goal than function.  Similarly, expecting this small staff office in HQ to 'design ... learning experiences for the work force to achieve the required cultural change ...' etc. may be unrealistic.  An appropriate role and function of this organization to serve as an advocate and proponent of employee eduction is not addressed. 		

Rationale:  Noted.  It is also emphasized that this HQ office will have the support of other field based units (i.e., RMECs, NMDCs, etc.) already in place to support the VHA employee education goals/functions referenced. 

Comment:  1.4  The Director National Media Development Center comments that he has many questions relating to formation of an Employee Education Office and how the resources of the National Media Development Centers (NMDC) will be utilized and fit within this new structure. 		

Rationale:  Many of these issues will be addressed upon appointment of the Chief Employee Education Officer.
	
Proposed Revision:	
1.4  Re-vised	Establish an Office of Employee Education aligned within the Office of the USH, and also create the position of the Chief Employee Education Officer reporting to the Deputy Under Secretary for Health (DUSH).  This office will be headquarters based, with a small HQ staff component (i.e., 5-7 FTEE).  The primary functions of this office will include:  the creation of a learning organization; the design of learning experiences for the work force to achieve the required cultural change and meet the education needs advanced by the Education and Training Workgroup; and the restructuring and integration of the existing VHA employee education network to maximize quality, efficiency, and cost effectiveness.

Recommendation:
1.5 Realign the functions of the Professional Affairs Staff (PAS) to other HQ offices, retaining only two functions in the Office of the USH assigned to the Deputy Under Secretary for Health.  These two functions include the management of the Distinguished Healthcare Executive Program (DHEP) and the Special Medical Advisory Group (SMAG).  The functions performed in support of the DHEP and the SMAG are to be absorbed by exisiting staff.  All other functions formerly performed by the Professional Affairs Staff should be transferred/realigned to other HQ offices.

Action Required:
1.5.1 Retain the functions of the DHEP and the SMAG aligned within the Office of the USH.

Action Office: Office of USH

Target Date: Oct. 1, 1995 

Action Required:
1.5.2 Transfer the staff (2.0 FTE) and the functions of the Chief of Staff Selection Process and Credentialing of HQ Title 38 Staff to the Management and Administrative Support Office (MASO) aligned under the Chief Administrative Officer  (CAO).

Action Office: Office of USH

Target Date: Oct. 1, 1995 

Action Required:
1.5.3 Transfer the staff (3.0 FTE) and the function of the National Credentialing and Privileging Policy to the Office of Patient Care Service (PCS).  This function includes Liaison with State Licensing Boards, National Practitioner Data Bank, Federation of State Medical Boards.

Action Office: Patient Care Services

Target Date: Oct. 1, 1995 

Action Required:
1.5.4 Transfer the Policy function related to Medical Staff By-Laws to the Office of Policy, Planning, and Performance (PPP).

Action Office: Office of USH

Target Date: Oct. 1, 1995

Action Required:  
1.5.5 Transfer from the PAS the function of the Chief of Staff and Clinical Managers Training Programs to the Office of Employee Education.

Action Office: Office of USH

Target Date: Oct. 1, 1995

Comment:  1.5.1 Clarification of DHEP, renamed to Distinguished Healthcare Scientist Program.  Suggests program administration responsibilities be realigned to the Management and Administrative Support Office (MAS0).  Since participants organizationally assigned to field VAMCs, visibility of program not dependent on HQ location but rather on accomplishments of individuals named. 	

D	

Rationale:  Noted

Comment:  1.5.5  Individuals (2) expressed concern whether funding to support these functions also would be realigned or if these programs would now have to compete with other employee education needs.	

Disapprove

Rationale:  Funding is issue for all programs. Irrespective of realignment, programs are not assured of funding and will need to compete.

Comment:  1.5.3  Two writers emphasized that credentialing and privileging and especially reprivileging are at the heart of an integrated risk management program.  One writer noted that the National Practitioner Data Bank and liaison with State Licensing Boards are frequently related to Tort Claims or other risk events.  Another writer emphasized that credentialling of professionals must be judged with the same criteria that were used to recommend the functional alignment of the professional performance measurement and the professionals development of medical by-laws.  For these reasons, a recommendation is made to move this function (i.e. National Credentialing and Privileging Policy) to the Office of PPP. 	

Disapprove

Recommendation:
1.6 During the HQ transition period, realign the Administrative Support Office staff (3.0 FTE) to the Chief of Staff (C0S) with permanent reassignment to the new HQ Administration function aligned under the Chief Administrative Officer, Management and Administrative Support Office (MASO).

Action Required:
1.6.1 Realign the Administrative Support Office (3.0 FTE) with the COS  for a transition period (NTE three months) with permanent reassignment to the  MASO.

Action Office: Office of USH, Chief of Staff

Target Date: Jan. 12, 1996

Comments: One writer expresses concern that the recommendation to transfer 3 FTE to the CAO is not self explanatory.  The writer points out that the current functions of the Administrative Support Office are not discussed within the report.  If the office is a component of the Professional Staff, it is not clear.  If the office of the Under Secretary no longer requires three administrative support staff, the writer questions why these positions are not identified for reduction rather than transfer.

Rationale: The transition period (NTE three months) has been suggested to permit the new  COS to make a determination of administrative support needs that may be ongoing in the new  Office of the USH.  The development of functions required within the new organization of the Office of the USH could not be specifically determined by the HQ  Restructuring Workgroup.  Specfics to include reductions of FTE levels are appropriate between the USH and the individuals responsible (i.e., the COS and/or CAO).


Recommendation:
1.7  Establish staff support for the Chief Network Officer (CNO) utilizing some (i.e., the health system specialists and some others, NTE 10-12 FTE) currently assigned to Operations.

Action Required:
1.7.1 Transfer programmatic staff currently in Operations to their counterpart programmatic offices in new HQ organization.

1.7.2 Identify and establish CNO Support Staff within the Office of USH from current Operations staff.

Action Office: Office of USH, CNO

Target Date: Oct. 1, 1995

Comment:  1.7.1  One comment requested clarification regarding the transfer of Operations staff to sucessor office by October 1, 1995, noting that the correlating increases in staff should be reflected in the appropriate offices.  An example provided was an increase of 2 FTE to be reflected in the Office of PPP. (Recommendation  1.13).	

Disapprove	

Rationale:  As noted throughout this report, several functions are proposed for review.   The FTE, if any,  associated with the functions to be retained upon realignment to new offices are pending determination.

Comment:  1.7  One writer expressed concern for the feasibility of the suggested new organization in view of the MAMOE levels expected for FY 1996.  The writer recommended the elimination of the VISN teams and associated HSS staff in the CNO office.  Given the four-dimensional mission of HQ offices, he emphasized that there should be no need for a liaison function between VISN and health care facility staff and the HQ/Service center offices that support them.  (See also recommendation  1. 24).	    

Disapprove

Rationale:  We strongly believe that there is a need for a link and/or liaison function between HQ and the VISNs and VAMCS, particularly in view of the scope of the reorganization.  This may indeed be a transitional organizational model based on future budget constraints.

Comment:  1.7  One writer expressed concern that this recommendation to establish support for the CNO does not follow  from a discussion or analysis of CNO functions or activities.  Justification or explanations for the number or type of staff, and roles of these staff  not clear.  The writer expressed further concern of whether roles were distinct from roles of VISN support teams.  The writer also noted that the CNO support staff should not include either a budget or planning function, since this is duplicative of other HQ functions and is not consistent with the mandate that all HQ elements must serve the field as customers.  The writer added that the total staff size proposed should be stated.		

Rationale:  Noted.   See revised recommendation 1.7 which clarifies role of these staff who are also members of the HQ VISN support teams referenced also in recommendation 1.24 of this report.

Proposed Revision:
1.7  Revised Establish staff support for the Chief Network Officer (CNO) utilizing some (i.e., the health system specialists and some others, NTE 10-12 FTE) currently assigned to Operations.   This group would also be used in HQ VISN Support Teams.

Recommendation:
1.8 Realign the National Clinical Ethics Center at White River Junction, from the AsCMD for Clinical Affairs, to the Deputy Under Secretary for Health (DUSH).  Most of the functions handled by this Center are cross-cutting and relate to overall policy in VHA.

Action Required:
1.8.1 Amend the policy and procedures memorandum on the National Ethics Center to realign it to report to the DUSH.

Action Office: Office of USH

Target Date: Oct. 1, 1995

Comments:  1.8 One commentary noted that the National Ethics Center and the Center for Clinical Ethical Decision-making in Portland should be considered a vital support resource.  The degree and the severity of change being considered make it imperative that the ethical implications of specific change are not ignored.

Approve

Rationale: Consistent with report.  No change in recommendation or action required.

Recommendation:
1.9 Business planning activities should be coordinated by the DUSH.  The workgroup considered several offices (CNO, PPP, CFO) as possible locations for coordination of business planning.  While this is recognized as primarily a VISN function, it requires guidance and coordination at the Headquarters level.  The DUSH, in conjunction with the CNO, is the appropriate official to bring all aspects of this function together in a unified HQ process.

Action Required:
1.9.1 The DUSH, in conjunction with the CNO, should develop a plan for initiating and coordinating a VISN-based business planning process.

Action Office: Office of USH

Target Date: Oct. 1, 1995 or sooner if possible.

Comments:  
1.9.1 Several writers (5) expressed concurrence with this action .  Many offices have a stake and interest in business planning, and the issue of where the responsibility lies needs to be definitively mapped out.

Approve

Rationale: Consistent with report.  No change in recommendation or action required.  Responsibility at DUSH level.


Recommendation:
1.10 The Under Secretary for Health should appoint the head of the Office of Policy, Planning, and Performance (PPP) as quickly as possible.

Action Required
1.10.1 Initiate recruitment activity in order to select a Chief of PPP as soon as possible.

Action Office:  DUSH

Target Date: Aug. 1, 1995

Comments:  None


Recommendation:
1.11 Structure.  There should be two groups within the Office of Policy, Planning, and Performance: (1) Strategic Planning and Policy, and (2) Performance Planning and Monitoring.   Specific task organization will include the areas used in the functional analysis to include:  Strategic Planning, Policy Analysis and Legislation, Performance Planning and Systems Development, Evaluation and Inspection, Risk Management and Utilization Management.    Discrete functional groupings of tasks within the Office are not recommended to encourage the free flow of information and talent across functional boundaries.

Action Required
1.11.1 Allow the new  Chief of PPP to determine the timeline for subdividing the office into two units:  Strategic Planning and Policy, and Performance Planning and Monitoring.

Action Office: Office of USH

Target Date: Complete timeline determination within 30 days of appointment of Chief of PPP.

Comment:  1.11  A group of commenters expressed concern regarding the structure of this office and emphasized the following, "The purpose of restructuring was to also decentralize decision-making to the field.  It would appear that by creating an Office of PPP, there is actually more centralization than decentralization.  The PPP office is very large and is faced with a daunting task.  We do not believe it is ever a good idea to have any one unit responsible for planning programs and monitoring the outcomes (performance) of these program.  The two mission, planning and performance, can be too intertwined and raise the question of conflict of interest.  We do see the logic in combining Policy and Planning; however, we believe the Performance component should remain separate." 	   

Disapprove

Rationale:  It is not the expectation that there will be more centralization of decision-making, or that a conflict of interest situation will result be aligning these functions to the Office of PPP.

Comment:  1.11  One writer expressed concern regarding the listing of current functions cited within the report that no longer would be required at HQ.  The commentary notes that "it is suggested that educational entities such as the QMI should move to the Chief Employee Education Officer.  This seems reasonable on the face, but one of the reasons these components came to be in the first place was the large unmet need in the system to address quality issues.  Care should be taken that when moving these components that responsiveness to needs of customers in HQ is maintained.  This would seem to be especially important at this time when there is a great need to train staff in some new concepts of performance management and measurement systems."	   

Approve

Rationale:  The suggestion is consistent with the report. Action 1.13.2 requiring review of functions being aligned to Office of PPP is revised to include the Chief Employee Education Officer as one of the individuals, together with the Chief of PPP and the CFO, conducting the critical analysis.

Comment:  1.11  One commentary emphasizes that with the transfer of training and education activities to the field and to the Office of Employee Education, it is not readily apparent why the identification of training needs and assistance in curriculum development should remain in PPP.   If the activity being retained is the same advisory function as currently performed by existing program offices in the development of training programs, it may be unnecessary to state this function explicitly.  As such, FTE to be moved to the Employee Education from the QMO and QMI should be identified.  		

Rationale:  The comment is consistent with the report.  Action 1.13.2 requiring review of functions being aligned to Office of PPP is revised to include the Chief Employee Education Officer as one of the individuals, together with the Chief of PPP and the CFO, conducting the critical analysis and determining FTE for realignment. 

Comment:  1.11  The Western Region Information Management Group agrees that the Office of PPP at the level of the USH makes sense, in particular to integrate operational and clinical planning efforts that have traditionally been segmented. 	

Approve

Rationale:  Commentary consistent with report, no change in recommendation or action required. 

Comment:  1.11  The Chair of the Employee Education Network states support for a shift of education and training activities performed by the Quality Management Institute (QMI) and Quality Management Officer (QMO) to the Office of Employee Education is appropriate and on target.  He notes that the OMI technically has been part of the Office of Academic Affairs but supported by the Office of Quality Management.  This writer recommends that the QMI which has had quasi involvement in the Employee Education Network become a full-fledged member of the Network and be fully accountable to the Chief Employee Education Officer. 	   

Approve

Rationale:  Commentary consistent with report.  The participation of the QMI as a member of the Network can be resolved after appointment of the Chief of PPP and the Chief Employee Education Officer.


Recommendation:
1.12 New Functions.  Two sets of functions should be added to the Office of PPP beyond the general ones discussed in the Vision for  Change.   These are (a) the OIG/GAO liaison function originally proposed to shift to the COS and (b) the Legislative programs function currently assigned to the Chief of Staff.

Action Required:
1.12.1 The OIG/GAO liaison function includes the review and analysis of OIG/GAO audits, developing the VHA position on them, and ensuring appropriate follow-up and corrective actions.  The OIG/GAO, Quality Management (QM), and Medical Inspector (MI) functions will all be strengthened and economies achieved in certain data base and follow-up activities if they are organizationally linked.  This also requires that the scope of MI and QM activities be extended beyond clinical matters and would make the establishment of an Office of Clinical Efficacy with these functions unnecessary.  (See also recommendation 1.2 and 1.45.2).   
Add the OIG/GAO function to the Office of PPP.

Action Office: Office of USH

Target Date; Oct. 1, 1995

Action Required:
1.12.2 The Legislative programs functions should be formally integrated into the policy analysis functions of the Office of PPP.  This would strengthen VHA legislative review.  In particular, the identification of legislative initiatives and the analysis of legislative proposals of other organizations requires close interaction with policy analysis.  With this function, the Office of PPP would assume the responsibility for preparing the DUSH and top VHA officials for hearings with associated scheduling and drafting responsibilities.  (See also recommendation 1.3). 
Add the Legislative Program function to the Office of PPP.

Action Office: Office of USH

Target Date; Oct. 1, 1995

Comments: A general comment is that it might be considered a conflict of interest to have the Medical Inspector (MI) and the OIG and GAO liaison function in the same office, especially if the writes a report that needs a coordinated response.  The writer suggests consideration of another location for one of these functions.

Disapprove

Rationale: Consideration of other locations of this function was reviewed by the workgoup, and location to the Office of PPP was viewed to be in the most appropriate.  This alignment is not expected to result in  conflict of interest.


Recommendation:
1.13 Initially, the Office of PPP should be comprised of both HQ staff and the field units currently reporting to it.  In general, the workgroup believes that Strategic Planning and Policy requires fewer staff than Performance Planning and Monitoring, and that Performance Planning and Monitoring requires fewer staff than proposed in the initial assignment.  These functions should be re-evaluated for integration, elimination of duplication, and whether they need to be redistributed to other units and/or programs within HQ.   All of these field based units identified to be realigned to the Office of PPP and those currently aligned with the Chief Financial Officer, such as the Management Science Group at Bedford, should be included as part of this review to determine their need and placement in the new organization.

Action Required: 1.13.1 Establish an Office of PPP initially with units currently reporting to it.

Action Office Office of USH

Target Date:  Oct. 1, 1995

Action Required: 1.13.2  Prior to realignment of new units, the new Chief of PPP, in conjunction with the CFO, will perform a critical analysis and review of functions and staffing of units under consideration for realignment  in the new office, including field units, with the goal of seamless integration and achievement of economies of scale.
	
Action Office Office of PPP

Target Date:  Completion by Jan.1, 1996 

Action Required: 1.13.3 All out placed field units realigned to PPP should be assessed within six months with respect to their continued existence, staffing, and reporting relationship to the PPP.

Action Office: Office of PPP

Target Date:  Downsizing completed by Mar. 1996.

Comments:  1.13  One writer expressed concern for the feasibility of the suggested new organization in view of the MAMOE levels expected for FY 1996.  This writer recommends elimination of the redundacies and fragmentation in planning through the merger of the COO/CNO planning staff, Facility Planning functions, and the CFO Business Planning function with the Office of PPP. 
	   
Approve

Rationale:  The review to be undertaken by the Chief of PPP in conjunction with the CFO and Chief Employee Education Officer will address this concern.   No change to the recommendation or action is required.

Comments:  1.13.2  Several comments (4) addressed a concern for the need and timing of this critical analysis.  The functions identified fall within the new PPP office, and the delay in reassignment of the staff was commented as counter productive in accomplishing the tasks (i.e., strategic plans, performance plans, etc.) required from this office.  One specific comment emphasized that the Planning Systems Group at Gainesville, the Management Science Group at Bedford, and the staff in the Office of the Director must be transferred with the appropriate functional  responsibility on October 1, 1995.  The writer added that an analysis performed by January 1, 1996 will not serve the organization well. 		

The target date appears reasonable to accommodate the appointment of a new Chief of PPP, and is viewed as a 'not to exceed' date for completion.  If the review can accomplished prior to the target date, it will be. 

Comment:  1.13  One writer commented 'to establish a smaller, more efficient, effective and exonomical organization' for the Office of PPP has not been realized with the size of the organization and staff proposed by this report.  	   

Approve

Rationale:  This commentary regarding size is consistent with deliberations of the workgroup.  Determination of the size of this office to be made after appointment of the new  Chief.  See revised action 1.13.2.

Comments:  1.13  One writer strongly emphasized concerns regarding the placement of the Management Sciences Group (MSG) located at Bedford from the CFO Office to the Office of PPP.  This writer emphasized the historical decision making rationale for placement of the MSG to its current organizational alignment.  This writer also suggests that if the MSG is not going to continue to focus on financial and budget issues, they should no longer exist as a separate entity and their elimination should be considered.  The writer also noted merging the MSG with evaluation functions in HSR&D, the MDRC, and the National Center for Veterans Analysis and Statistics as options.		

Rationale:  Noted.  The report does not provide a final determination on the position of this unit, and emphasizes that any decisions regarding the transfer of FTE from the CFO to other components is predicated on completion of  a critical analysis by the principal stakeholders (to include the new  Chief of PPP and the CFO).

Proposed Revision:
1.13.2  Revised Prior to realignment of new units, the new  Chief of PPP, in conjunction with the CFO and the Chief Employee Education Officer, will perform a critical analysis and review of functions and staffing of units under consideration for realignment in the new office, including field units, with the goal of seamless integration and achievement of economies of scale.   Field representation at the level of a VISN or VAMC director will also be included as Chairperson of the task force completing this review.  A report with recommendations will be provided to the DUSH.

Action Office; Office of USH

Target Date: Completion by January 1, 1996 

HEALTHCARE PROGRAMS - Recommendations 1.14 through 1.23	

		
General Comments:  One writer emphasized that both this report and the VISN report are silent concerning technology assessment (high cost/high tech equipment, procedures, and pharmaceuticals).  Technology assessment affects hundreds of million of dollars in expenditures, and we recommend that the reports address where technology should occur in VHA.   Should it be under R&D?  Should parts be addressed by the National Center for Cost Containment?  Should we buy technology assessment products/reports off-the-shelf?  Should it be a local function? Finally, should VHA have a coordinating body/office/person for technology assessment to reduce the potential for redundancy.	

Approve

Rationale:  Commentary makes a good point.  Technology assessment is currently fragmented and dealt with by a number of elements within VHA.  A process for the review of this matter should be determined at the National level.  It is recommended that the DUSH convene a multidisciplinary task force to review this issue.  The group should be chaired by the COS with participation of the CFO, CIO, Director R&D, Chief PCS Officer and field representation  at the level of VISN director.  See addition of action 1.0.1, under Office of PPP, Chief of Staff. 

Comments:  One writer recommended the inclusion of a detailed statement of Research & Development HQ functions within the report (Section IV.A.) following the Issue Statement, 'R&D has a well defined mission as stated in the Vision  for Change.'	 

Disapprove

Rationale:  The recommendation made by  the workgroup (reference 1.23) did not change the VHA functions of R&D, and was limited to realigning currenly performed Rehabilitation R&D functions.  The space constraints associated with the final  report would not make inclusion of this type of information feasiblewhen unrelated to the action/recommendation being proposed.

Comments:  Several writers (5) including the ACMD for Dentistry recommended a multidisciplinary council  to support VISN and HQ functions.  Commentaries varied on the name of this council, but each writer emphasized the potential for enhanced quality of service, program and professional development. 	

Approve

Rationale:  This recommendation has merit, and should be considered by the Chief Patient Care Services (PCS) Officer.  See added action 1.16.3 which assigns this responsibility to the Chief PCS Officer.

Recommendation:
1.14 Patient Care Services will be structured to have five Strategic Healthcare Groups (SHG's)  each responsible for a cluster of product lines with a commonality of purpose.  Each of the Strategic Healthcare Groups will address issues that involve the continuum of care, including both inpatient and outpatient settings.  The five groups are Primary Care, Acute Care, Geriatric/Extended Care, Rehabilitation, and Mental Health.  Within Strategic Healthcare Groups are Product Lines.  Each Product Line consists of a related group of programs or services that meet the needs of a specific patient population.  These Product Lines will include, but are not limited to, the Special Programs as outlined in theVision for Change.   Other examples of product lines within the Strategic Healthcare Groups could be the Organ Transplant Program and programs integrating a medical and surgical focus, such as, cardiothoracic and neurologic programs.  There will be no Clinical Support product line as identified in theVision for Change.

Action Required:  1.14.1 Operationalize Patient Care Services through the establishment of five SHGs as defined, with each SHG responsible for a cluster of product lines.   The five groups are Primary Care, Acute Care, Geriatric/Extended Care, Rehabilitation, and Mental Health.

Action Office: Office of USH

Target Date: Oct. 1, 1995

Comment: 1.14  	Several writers (3) recommend the realignment of Readjustment Counseling, albeit politically sensitive, under Patient Care Services, assigning the Vet centers to their respective VISNs.   It was emphasized that Readjustment Counseling should not be an independent office.	 

Disapprove

Rationale:  Although this recommendation has merit; realignment of this program is not  politically feasible at this time.	
	
Comment:  1.14  Several writers (6)  expressed difficulty in understanding the differentiation among the five SHGs.  
  One comment emphasized that there would be a lot of overlap among these groups and strict adherence to them would result in continuuing fragmentation of patient care.  A possible solution recommended is to somehow subordinate all groups to the primary care discipline with cross fertilization as needed between others.  Examples include mental health and rehabilitation to overlap geriatrics and extended care; acute care overlaps to geriatrics or mental health. 
   Comments (4) noted that primary care and acute care as unique product lines may be in conflict with the stated SHGs role in addressing the continuum of care in both inpatient and outpatient settings.  It was recommended that providing an operational definition of product line may assist to clarify this matter.	  

Approve

Rationale:  See clarification of the structure of PCS, definitions of both SHGs and Special Programs have been expanded.  See below revised 1.14 for the full text of the revised recommendation .	
	
Comment:   1.14  Another writer emphasized that the SHG did not achieve an ideal product line approach, and suggested that product line management would be better served with definitions like primary care, tertiary care, long term care, and rehabilitation with an exception that all product lines will involve multidisciplinary approaches.  Consideration of a preventive care product line was also suggested. 	

Approve

Rationale:  See clarification of information on the structure of PCS in the proposed revised action 1.14.2. 		

Comment:  1.14  One writer suggested that more information on how product lines work in other corporate settings was needed. 	

Disapprove

Rationale:  The final report was not required to go into this level of detail. 		

Comment:  1.14  One writer recognized that a tangential reference to a Pharmacy Benefits management (PBM) product line had been made within the report.  (1) A recommendation is made to incorporate an action item regarding PBM in this report assuming that a decision has been made to establish PBM.  The decision to incorporate certain functions (such as PBM) during the initial transition phase (to the new organization) would assure that significant product lines don't experience a period without representation and management, assist with integration with other offices, and assure continuing attention to significant legislative issues related to the product line.   (2) In the same context, no action item/milestone is contained within the report that addresses when VHA would identify other product lines noted in the report (i.e., transplant, cardiothoracic, and neurologic programs).  A recommendation is made that these areas be addressed now to assure continuity and integration and to prevent future "turf" issues.	   

Approve

Rationael:  Concur that consideration of other product lines is a valid concern, and a process should be identified early in the implementation phase of the new organization to assure appropriate coordination as new offices, functions, and objectives evolve.  It is recommended that the new Chief of Patient Care Services, in conjunction with SLG leaders,  identify a process for the identification of other product lines for implementation upon approval of the USH.  		

Comment:  1.14  G.V. (Sonny) Montgomery  (Ranking Member of the CVA) indicated surprise that the proposed reorganization of Central Office makes no specific provision for carrying out the board range of activities currently managed by Pharmacy Service.  He cites the magnitude of VA pharmaceutical expenditures of $1 billion annually which makes inexplicable a restructuring which would appear to fragment or eliminate the centralized expertise of a HQ team of pharmacists.  While that group need not function as a Pharmacy Service, the failure to maintain an office or support group to focus consistently on pharmaceutical costs and cost increases, drug utilization, and quality would represent a major step backward in his opinion.  He emphasizes that existing law does call for a Central Office Pharmacy Service, and Congress has had sufficient concern over VA costs in procuring drugs to enact drug pricing legislation.  He notes that the law is not self executing, it requires monitoring and reporting; and imposes ongoing  responsibilities on VA. 	

Approve

Rationale:  The question of pharmacy emphasis has been addressed.  The possiblity of a Pharmacy Benefits Management product line has been recommended by the workgroup  pending determination /action of the new Chief Patient Care Services Officer.   (See action 1.14.2). 		

Comment:  1.14  The Director, Blind Rehabilitation Service questioned the intent of the definition given for Special Programs.  He comments that, "The statement indicates that all VISNs will be required to be able to provide access to an inpatient Blind Rehabilitation Program, regardless of whether they have one of the programs in their VISN."  He asks, How broad a definition is the term 'access' and could access be interpreted as meaning 'to non-VA blind rehabilitation program or contracting for services from private sector facilities, especially when these outside programs do not equal the quality of the inpatient VA program?	

Disapprove

Rationale:  The distribution of scarce resources referenced within this comment applies to all programs, not just Blind Rehabilitation.  Inter-VISN relationships for the sharing of resources will have to be determined by the new cadre of VISN directors as the new organization evolves.		

Comments:  1.14  Several writers (5) endorsed the concept of the Office of Patient Care Services, noting that the five SHGs proposed very well emulate the product lines at many of the VAMCs and provides representation to the core providers of clinical services.  One writer did question the need to retain the separateness of some programs, such as Veterans Outreach and its centers; and a suggestion was made that further  review of this distinction be made as the new organization evolves. 

Disapprove

Rationale:  Although this recommendation has merit; realignment of this program is not  politically feasible at this time.		

Comment:  1.14  One writer in HQ expressed concerns for the diminishing visibility of the professional services component at the HQ level that may ultimately de-stablize the health care system.   In response this writer recommends the creation of two new organizational components ; (1) a Professional Accountability Council to include representation from Social Work Service and other core services , and (2) an interdisciplinary Program Office for Family and Community Services.  It was emphasizes that the consolidation of this program into a Family and Community 'product line' of services would promote system wide expansion and marketing of a vital customer service.  	   

Approve

Rationale:  These suggestions should be considered by the Chief PCS Officer.  See revised recommendation 1.14.2 and 1.16.3.		

Comment:  1.14  Several writers (2) emphasized that the SHG-product lines have long been utilized within the VA in an interdisciplinary approach, emphasizing that this is not a new concept and is only a title change.  A writer emphasizes that VHA product lines have functioned without the destruction of discipline specific identity.  The writer further notes that many private medical centers in the New Orleans area are now returning to discipline specific product lines, with an interdisciplinary approach to patient care. 	   

Disapprove

Rationale:  Not aware of any contemporary literature that is contrary to our concept of product line development.		
	
Proposed Revisions			
1.14 Revised
	Patient Care Services will be structured to have five Strategic Healthcare Groups (SHGs)  each responsible for a cluster of product lines with a commonality of purpose. 
 Each of the SHGs will address issues that involve the continuum of care, including both inpatient and outpatient settings.  The five groups are Primary Care, Acute Care, Geriatric/Extended Care, Rehabilitation, and Mental Health.  
 Strategic Healthcare Groups at the HQ level exist to coordinate aspects of patient care that have a common purpose.  Many aspects of patient care will involve several or all of the SHGs.  This will necessitate constant dialogue between and among the SHGs to develop performance goals, policy, best practices, and outcome measures that improve patient care to our veterans.
 Within Strategic Healthcare Groups are Product Lines.  Each Product Line consists of a related group of programs or services that meet the needs of a specific patient population.  The existence of Special Programs within VHA is one of its strengths.  These areas of exceptional interest and expertise reflect, to a large extent, what makes care to veterans unique.  Each of the Special Programs as outlined in the Vision for Change  will be retained.  They will be located organizationally in one of the SHGs.  By having a "home" in a SHG those Special Programs that meet the related needs of the veteran can best coordinate their efforts.  These Product Lines will include, but are not limited to, the Special Programs as outlined in the Vision for Change.  Other examples of product lines within the Strategic Healthcare Groups could be the Organ Transplant Program and programs integrating a medical and surgical focus, such as, cardiothoracic and neurologic programs.  The product lines as described above obviate the need for the Clinical Support product line as identified in the Vision for Change.					

1.14.2 Addition	 
The new  Chief of Patient Care Services, in conjunction with SLG leaders, will identify a process for the identification of other product lines for implemen-tation upon approval of the USH.   Consideration of other product lines should include the review of proposals for Pharmacy Management Benefits, Family and Community Service, and Preventive Care.
	
Action Office:  Patient Care Services	

Target Date :  NTE 30 days from appt of  the Chief PCS			

1.14.3 Addition	
The Women Veterans Program has developed over the years under the guidance and encouragement of the Office of Public Health and Environmental Hazards.  As a Special Program, it would best fit in the new organization in one of the Strategic Healthcare Groups, specifically primary care.  As an emerging Special program the need for organizational change is not as great as the need to nurture its development.  No action is recommended at this time to realign this program.  Consideration should be given at some future time to moving the Women Veterans Program to the Primary Care SHG.  See also recommendation 1.19.	

Action Office:  DUSH	

Target Date :  Deter-mination NTE 9/30/96.


Recommendation:
1.15 The Strategic Healthcare Group (SHG) staff will function in an interdisciplinary, collaborative manner both within each Strategic Healthcare Group and across Strategic Healthcare Groups.  The core function of each Strategic Healthcare Group are to:  (1) Support the Secretary and the USH by providing clinical expertise, drafting testimony and by preparing legislative proposals, budget proposals (in conjunction with the VISNs), background and position papers; (2) Respond to correspondence and inquiries from Congress, GAO, OIG, other federal agencies, Veterans Service Organizations, and establish partnerships with both public and private organizations; (3) Develop and contribute to their Product Lines by establishing performance goals, policy, best practices, and outcome measures to determine effectiveness; and (4) Support the VISN by serving as a consultant and determine effectiveness; and (4) Support the VISN by serving as a consultant and providing a clearinghouse function, when appropriate.

Action Required:	
1.15.1  	Develop performance objectives and/or group charters for each SHG,  and performance standards for each staff member of the Patient Service Group. 	

Action Office: Chief Patient Care Services (PCS) Officer

Target Date:  Nov. 1, 1995

1.15.2	Develop an operating budget for each SHG.  For example, these groups need to be able to bring in field-based people to deal with specific issues.	

Action Office: Chief PCS Officer

Target Date: Nov.1, 1995

1.15.3 
	Members of each SHG, in conjunction with the Chief PCS Officer, will make recommendations regarding adjustments in the membership of each SHG.	

Action Office: Patient Care Services

Target Date:  Nov. 15, 1995 

1.15.4 	Each SHG should formulate a strategic plan after group members and leaders have received necessary training.		

Action Office: Patient Care Services

Target Date: Jan. 12, 1996

Comment:  1.15  The Director, PM&RS provided a sampling of activities to define how its decentralized program operation, now in Memphis,  functions in concert with the description of the SHG.  He also emphasized that the services provided were far beyond those proposed for the discipline-specific leaders (in 1.18)., and questioned if they would be limited to the narrow scope described.  He questioned also if staff of the SHG would include decentralized service staff such as PM&RS. 	  

Approve

Rationale:  The information is helpful, but too detailed for inclusion within the final report due to space constraints.  This determination will be made by the Chief PCS Officer as the new SHG structure evolves. 

Comments:  1.15.1  One writer requested clarification regarding performance evaluation for staff of the SHG.  This writer notes that the functions of SHGs listed within the report imply that every SHG staff person will be evaluated on performance of at least two major functions, including VISN support.  She points out that this appears inconsistent with information provided for the VISN HQ support teams that states one staff from each SHG will be selected for each VISN support team. 	   

Disapprove

Rationael:  The functions of SHGs listed are not inconsistent with information provided for the VISN HQ support teams.

Comments:  1.15.3  One commentary requested clarification asking, 'to whom will recommendations be made, i.e., DUSH, USH, etc.?'
	   
Disapprove

Rationale:  The recommendations will be submitted to the Chief PCS Officer for determination.

Comments:  1.15  One commentary suggested that an action item be added which permits the Chief PCS Officer to determine the most appropriate staffing mix of the SHG.  This may include assignment of a professional to more than one SHG.  
	   
Approve

Rationale:  The comment is consistent with the report.  See revised recommendation 1.17 and action 1.17.2.a.

Comments:  1.15  One individual noted that the functions identified for SHGs appear appropriate.  However, this writer questioned the constant referral to interdisciplinary activities, at this time, does not appear reasonable under the present organizational structure of American Medicine.
	    
Disapprove

Rationale:  The trend to support interdisciplinary activities is in concert with the structure of American Medicine and the standards of JCAHO.

Comments:  1.15.4  Request for clarification as to how this SHG strategic plan differs from the VHA strategic plan and from the VISN Business Plans	

Approve

Rationale:  This is an extension of the VHA strategic plan as each SHG must determine goals/objectives for their respective product lines on a global basis.  These SHGs, through their leaders and the Chief Patient Care Services Officer, would work in concert with the Office of PPP  to formulate the VHA plan (reference diagram provided for Office of PPP, Section IA of report).  In response to the VHA strategic plan, each VISN would operationalize these objectives in their respective business plans. 

Diagram:

Composition of the SHGs:
Numerous  (18) comments received indicated that a specific professional and/or technical group (i.e., nurses, social workers, dentists, pharmacists, chaplains, rehabilitation professionals, dietitians, laboratory and radiology staff, etc.) had not been included or depicted in the SHG.  Several writers (9) emphasized that the omission and/or exclusion of their specific professional  group would be met by opposition from the specific organization representing the interest of the discipline or the absence would impede the continuity/quality of patient care.   Other commentaries requested further clarification of how the discipline specific membership for each SHG would be determined.  One writer requested clarification on whether the SHGs membership would include decentralized service staff, such as PM&RS. 	

Approve

Rationale:  It is recognized that these various SHGs will require cross  disciplinary representation.  As the leaders are selected and the teams are implemented and evolve into working units, these determinations will be made and adjusted.  To this end, the workgroup believed that action 1.15.3 is appropriate.


Recommendation:
1.16 Staffing:   A Chief Patient Care Services (PCS) Officer will coordinate the activity of all groups within Patient Care Services.  The Office of the Patient Care Services will consist of staff from Clinical Affairs and those members moved from the Professional Affairs section in the Office of the Under Secretary for Health (10 FTEE).  This person will also facilitate PCS activities both with the other units within Healthcare Programs (i.e., Office of Academic Affairs, Readjustment Counseling, Research and Development, and Public Health/Environmental Hazards) and with the Support Programs.

Action Required:  1.16.1 Select the Chief Patient Care Services Officer who will have responsibility to coordinate the activity of all groups within Patient Care Services.

Action Office: Deputy Under Secretary for Health

Target Date: For appointment NTE Oct. 1, 1995

Action Required:  1.16.2 Establish the Office of the PCS with staff from Clinical Affairs and those members aligned from the PAS not to exceed 10.0 FTEE.

Action Office: Deputy Under Secretary for Health

Target Date: Oct. 15, 1995

Comments:  1.16.2  One comment indicated that the chief of patient care should have within his/her office experts in the clinical disciplines which have been shown to be essential in maintaining the high quality of care. 

Approve

Rationale;  The options presented within the report provide for the USH to make these selections as he deems appropriate.  This commentary is consistent with the report, no change in the recommendation or action required.

Comments:  1.16.1  Several comments (5) were made regarding the Chief Patient Care Services Officer position  not being limited to physicians.  One writer recommended that this position should be occupied by a nurse. 	

Approve

Rationale:  No specific reference has been made by the workgroup that defines the qualifications for this position that is identified within the Vision for Change.  We agree that the Chief PCS Officer does not need to be a physician, and emphasize only that this individual should have appropriate patient care experience.   The HQ workgroup points out the option exists not to appoint the AsCMD for Clinical Affairs pending legislative relief from the Title 38 requirement.

Comments:  1.16.1  Comments (3) were received objecting to the function assigned to the Chief Patient Care Services (PCS) Officer for the triage of discipline-specific issues and serving as the initial contact from professsional ogranizations.  It was noted that this created an additonal administrative layer,  described as  burdensome and having the potential to could cause communication problems delaying action on critical issues. 

Approve

Rationale:  The commentary has merit, and agrees to omit the triage function, described within the report,  from those assigned to the Chief PCS Officer.   No change in report recommendations or actions required.

Comments:  1.16.1  One Chief of Social Work Service questions the need for a Chief Patient Care Services Officer, noting that the product lines are the core of the system.  The writer questioned that if this is to become an important function why would another layer be added between the USH and the Strategic Healthcare Groups?  

Disapprove

Rationale:  The Chief PCS Officer represents theHQ coordinating element between product lines and the USH.
	
Proposed Revision		
1.16.3  Ad dition	
The Chief PCS Officer will review proposals for the establishment of a multidisciplinary council(s) to support HQ and VISN functions.  The establishment of council(s) should emphasize quality of service, program, and professional development in addition to addressing concerns related to the lessening visibility of professional services/disciplines as components in VHA decision making.   Recommendations regarding establishment will be made to the DUSH.	

Action Office :  Patient Care Services	

Target Date :  Jan. 12, 1996

Recommendation:
1.17 There will be a leader of each Strategic Healthcare Group who will be appointed by the Deputy Under Secretary for Health (DUSH) and who may be selected from any discipline.  However, in aggregate, these leaders should represent a diversity of professional disciplines.  All Strategic Healthcare Groups will consist of a core interdisciplinary team supplemented, as appropriate to the needs of the group's product lines, by staff from additional disciplines.  The staff of the Strategic Healthcare Groups will come from current Clinical Affairs and will consist of 10 to 20 FTEE per Group.

Action Required: 1.17.1 Designate a leader for each Strategic Healthcare Group.

Action Office: Deputy Under Secretary for Health

Target Date: Oct. 15, 1995

Action Required: 1.17.2.a Assign present members of Clinical Affairs to the five SHGs, such that each team consists of a core interdisciplinary composition of no more than 10 to 20 FTEE per SHG.

Action Office: Chief, Patient Care Services Officer

Target Date: Nov. 1, 1995

Action Required: 1.17.2.b. Develop a plan,  in conjunction with the Management & Administration Support Office (MASO), to assist those former Clinical Affairs staff who prefer to be placed elsewhere.

Action Office: Chief, Patient Care Services Officer

Target Date: Nov. 1, 1995

Comment:  1.17.  Several writers (3) emphasized concerns that the proposed time frames appear to be unrealistic to accomplish well thought out changes in our massive system.  Some functions can not be shifted until staff are identified and assigned.  A recommendation that at least one month span of time between each of these major actions be considered as a more appropriate target.	

Rationale:  The USH has indicated that actions be taken quickly, when  recommendations are approved.  

Comment:  1.17  One writer expressed concerns that the teams would become silos in and of themselves if a fair representation of services were not assured.   The presence of a variety of disciplines was emphasized as a means to eliminate parochialism and implement a true team approach.   However beyond team training, the writer requested that the workgroup identify a means to effectively change behavior.	

Disapprove

Rationale:  While it is possible that the teams would become parochial in their behavior, the goal and expectation is that they are to be integrated work teams.

Comment:  1.17.1  A VAMC Director recommended that the Chief Patient Care Services Officer (PCSO) nominate leaders for each SHG for concurrence by the DUSH.	    

Disapprove

Rationale:  See revised recommendation 1.17 and revised action 1.17.1.

Comment:  1.17  One writer requested clarification of the organizational relationship of the Chief Patient Care Services Officer (PCSO) and the SHG directors.  This writer also expressed concern regarding the new roles and number of staff currently assigned to Clinical Affairs that will be reassigned to the newly created PCS Office and the SHG teams.  The commentary requested clarification of what all these people will be doing, and emphasized that the benefits to be obtained by out placing the SHG directors are more than offset by creating a large central bureaucracy in HQ to support each of these directors. 		

Rationale:  Recommendation 1.17 and actions 1.17.1 and 1.17.2 are revised to provide clarification.  This report does not address the out placement of SHG leaders, which the writer has confused with discipline specific leaders addressed in recommendation 1.18.  The workgroup deliberations were consistent with the commentary regarding the number of staff assigned from Clinical Affairs in support of the new  SHGs, and identified this area for reduction in the report introduction.
	Proposed Revision	
1.17  Revised	There will be a leader of each Strategic Healthcare Group (SHG) who will be appointed by theChief Patient Care Services (PCS) Officer, in conjuntion with the Deputy Under Secretary  for Health (DUSH), who may be selected from any discipline.  However, in aggregate, these leaders should represent a diversity of professional disciplines.  All Strategic Healthcare Groups will consist of a core interdisciplinary team supplemented, as appropriate to the needs of the group's product lines, by staff from additional disciplines.  The staff of the Strategic Healthcare Groups may come from current Clinical Affairs and will represent a limited number of core staff.  Each SHG will be augmented by field based expert panel groups.  		

1.17.1 RevisedThe Chief PCS Officer, in conjunction with the DUSH,  will designate a leader for each SHG.	

Action Office:  DUSH	

Target Date :Oct. 15, 1995

1.17.2  Revised	The Chief PCS Officer will assign present member of Clinical Affairs to the five SHGs, such that each team consists of a core interdisciplinary composition.	

Action Office:  Chief PCS Officer	 

Target Date :  Nov. 1, 1995

Recommendation:
1.18 In the development of this plan, options are presented regarding placement of discipline-specific offices.  The benefits of discipline-specific leaders at Headquarters were not as strong as the need to break down the discipline-specific "stovepipes" that had developed over the years.  While the workgroup believes that there are definitive advantages to locating the discipline specific leaders in the field, it also recognizes that this approach should be flexible, and reflect personal circumstances and changing organizational needs.  The placement of the discipline specific leader is recommended in the following descending order:  (1) Discipline specific leaders should be located in the field.  (2) Senior staff currently serving in HQ as discipline specific leaders may be permitted to request to remain in HQ until their current appointments expire.  (3) It is understood that the USH always reserves the flexibility to appoint the discipline specific leader in HQ depending on the needs of the discipline, the availability of a superior candidate, or other factors.  In order to determine who remains in Headquarters and who is to be returned to the field, there would be a requirement that a workplan be developed that specifies projects, products and desired outcomes.  The decision would be based upon which location best serves the interest of VHA.

Action Required
1.18.1 The DUSH will approve discipline-specific leaders, who will be field-based and will function similar to the current decentralized Service Directors.  These discipline specific leaders will have two major functions in their national roles -- liaison with national professional organizations and coordination of discipline-specific issues.

Action Office: Office of USH

Target Date: Feb. 1, 1996

Action Required
1.18.2 Identify changes in field based placement of discipline specific leaders, if indicated, upon development and review of the workplan.

Action Office: DUSH

Target Date:  To be determined as needed

Comment:  1.18  Concerns (4) were expressed that the statement regarding discipline-specific leaders would infer that the reference is to only  title-38 appointees.  Thereby excluding other clinical professionals (i.e. physical and occupational therapy, social work,  dietitians, etc.).  Suggestions (6) were made that  further clarification as to qualifications, role, function, and the process for the selection of these leaders should be provided. 

Rationale:  These positions are not limited to title 38 appointees.

Comments:  1.18  Several writers (10) believed that directors of the major clinical disciplines should be retained in HQ.  Comments cited in support of retaining these leaders in HQ include more focused function for patient care, the need for representation in each product line section, direct consultation with USH,  and organizational examples correlating to university hospitals.   The Nurse Organization of Veterans Affairs (NOVA) also cited co-location in Washington DC as essential to interface with  nurse professional associations and to advance the DVA legislative agenda for patient care.   Specific commentary (19) from nurses throughout the field was also received affirming the need for a 'nurse' leader and/or executive at HQ level with appropriate staff support.	

Disapprove

Rationale:  The option of retaining or placement of the discipline leader in HQ is available to the Under Secretary for Health as delineated within this plan.  No change in recommendation or action statement required.

Comments:  1.18  Concerns (5) were expressed regarding communication linkages with field based leaders and how these leaders would access information necessary to keep them abreast of current issues.  The authority for decision making, level of HQ support to these field based leaders, and the participation of current decentralized Service Directors to interact with other HQ offices were cited as cautionary and problematic unless the communication issues were thoughtfully addressed.  Other individuals (4) expressed concern with the impact and effectiveness of a field based leader, and the duality of his/her functions and their ability to also meet competing  responsibilities at their local VAMC.

Rationale:  These concerns were addressed in workgroup deliberations recognizing that discipline specific leaders would require funding and technology support to facilitate telecommunications and travel.

Comments:  1.18  A question was raised regarding who will have responsibility for developing the workplan referenced?
	  
Approve

Rationale:  The workplan would be developed by the discipline specific leader that wanted to be located at HQ.  A revision to the action statement is provided. 
Comment:  1.18  Several individuals (Dentistry, Social Work, Nursing, Pharmacy, Chaplain, and others) expressed concerns (15) regarding whether representation of their particular discipline would continue to be represented by a designated leader.  Many individuals (3) believed it would be more representative to have mandated positions for each of the major disciplines.   		

Rationale:  This matter is not a process under review by the workgroup.  The decision continues to be made by the DUSH, based on the needs of the organization.
Comment:  1.18.1  One Chief Nurse made reference to the relationship of the clinical disciplines with professional organizations.  The commentary notes that 'it is unclear if this is the only value of disciplines in HQ, why this function could not be aligned with the VISN office.  It is of value that the report does see the importance of credentialing and standards guided by the discipline.'  The writer adds that she also sees policy decisions that should be made for VHA that should be discipline specific.  She closes by emphasizing that 'National policy for all disciplines should assist in standardizing specific patient and personnel issues that will cut across VISN boundaries. 		

Rationale:  Concern addressed in recommendation 1.18 as written.

Proposed Revision	
1.18  Revised  In the development of this plan, options are presented regarding placement of discipline-specific offices.  The benefits of discipline-specific leaders at Headquarters were not as strong as the need to break down the discipline-specific "stovepipes" that had developed over the years.  While the workgroup believes that there are definitive advantages to locating the discipline specific leaders in the field, it also recognizes that this approach should be flexible, and reflect organizational circumstances and changing needs.  The placement of the discipline specific leader is recommended in the following descending order:  (1) Discipline specific leaders should be located in the field.  (2) Senior staff currently serving in HQ as discipline specific leaders may request to remain in HQ until their current appointments expire.  (3) It is understood that the USH always reserves the flexibility to appoint the discipline specific leader in HQ depending on the needs of the discipline, the availability of a superior candidate, or other factors.  In order to determine who remains in Headquarters and who is to be returned to the field, there would be a requirement that a workplan be developed that specifies projects, products and desired outcomes.  The decision regarding placement would be based upon which location best serves the interest of VHA.		

1.18.2  Revised	Identify changes in field based placement of discipline specific leaders, if indicated, upon review of the workplan developed by the discipline specific leader under consideration for placement in HQ.

Action Office:  DUSH	

Target Date :  To be determined as needed


Recommendation:
1.19 Special Programs, as defined in the Vision for Change , have remained intact but are organizationally placed under appropriate Strategic Healthcare Groups.  Special Programs are distinguished from other Product Lines because every  VISN will be required to provide access to all  Products in that Product Line.  For instance, all VISNs will be required to be able to provide access to an inpatient Blind Rehabilitation Program, regardless of whether they have one of the programs in their VISN.

Action Required
1.19.1 Realign the Women Veterans Program to  Patient Care Services in their Primary Care Strategic Healthcare Group.

Action Office: Patient Care Services

Target Date: Nov. 1, 1995

Comment:  1.19  A recommendation was made that Traumatic Brain Injury should be afforded Special Program status within the Rehabilitation product line, considering the complex needs of the veteran population and the mandate to provide access to such services within all the VISNs. 	  

Disapprove

Rationale:  Not a Special Program as defined in the Vision for Change.

Comments:  1.19  One writer expressed concern that little attention was given to Special Programs, and the development of policies for supporting these programs was not addressed by the workgroup.  While the writer recognizes the reorganization as an evolutionary process that is not taking place overnight, the environment being created presents cause for concern.  The recommenation stated by the workgroup may nullify Objective 1 of the Prosthetics Improvement Implementation Plan concerning expanded CO management and jeopardize Objectives 4 and 5 concerning program oversight. 	  

Approve

Rationale:  See clarification of definitions for SHGs and Special Programs under the structure of Patient Care Services (for full text see revised recommendation 1.14).   Addition reads, " The existence of Special Programs within VHA is one of its strengths.  These areas of exceptional interest and expertise reflect, to a large extent, what makes care to veterans unique.   Each of the Special Programs as outlined in the Vision for Change  will be retained.  They will be located organizationally in one of the SHGs.  By having a "home" in a SHG those Special Programs that meet the related needs of the veteran can best coordinate their efforts.    

Comment:  1.19  G.V. (Sonny) Montgomery  (Ranking Member of the CVA) expressed concerns regarding the future of VA's specialized medical programs, which have historically been vulnerable, particularly during periods of budget constraint.  He emphasizes that unprecedented outyear budget pressures coupled with the proposed decentralization heighten the risk that these often costly programs will be at risk and in need of fiscal, structural, and other protective mechanisms.   He notes that the reports appear to subordinate and blur the specialized services mission, rather than reflecting a policy aimed at ensuring the vitality of the programs.   He adds that it is ironic that an agency which does not now even have a primary care mission in law is proposing to make the expansion of 'primary care' a systemwide performance goal while remaining silent on any such goal regarding critical specialized programs. 	

Disapprove

Rationale:  The concerns about the Special Programs are addressed in a clarification of the definition provided under Patient Care Services.  It should be emphasized that Special Programs are maintained in the new organization and are grouped in areas where they can have maximal impact on veteran care.  Primary Care is not a mission of the VA but a method of making sure that patient care needs are addressed to the fullest extent.  It is an attempt to keep problems from falling through the cracks and not an attempt to de-emphasize Special Programs.  The goal of Primary Care is to coordinate the care of our veterans especially those in Special Programs.  

Comment:  1.19  Two commentaries received requested clarification of the way special programs were defined.  One writer did not understand how VISNs can be expected to guarantee access which is implied in the current formulation of the statement.  Rather their understanding was that VISNs will have to have policies for referrals to special programs.		

Rationale:  The distribution of  and/or access to scarce resources referenced within this comment applies to all programs, not just Special Programs.  Inter-VISN relationships for the sharing of resources will have to be determined by the new cadre of VISN directors as the new organization evolves.

Comments:  1.19.1  Writers (5) expressed concern regarding the movement of the Women Veterans Program.  One writer acknowledges that the rationale for placement of the program under Environmental Medicine and Public Health is somewhat vague.  However, as emphasized by the workgroup, the program is working well.  Coordination of these activities by the current program official has helped prevent fragmentation of women's services that existed in the past and contributed markedly to progress.  At this juncture, organizational realignment is viewed as disadvantageous to continued program growth. 	

Approve

Rationale:  As not to impede continued program growth and in consideration of other implementation issues which must be resolved as the SHGs evolve,  consideration should be given to adjusting the target date for this realignment  to the primary care SHG and should be determined NTE 9/30/96.  Recommendation for SHGs (1.14.2) is broadened to include information on the Women Veterans Program, and the action 1.19.1 is changed. 

Comment:  1.19  One Chief Nurse comments that the realignment of Women Health Care with Primary Care Services is a positive.  However,  she highly recommends that performance measures be directed at complying with standards that ensure that practitioners are knowledgeable and skilled in this area.  She further recommends that priority be given to developing performance measures that will increase market-share of women veterans,  and accountability for improving services through preventive health programs.		

Rationale:  See revised recommendation 1.14, revised action 1.14.3 and the rationale provided in the comment above.

Comments:  1.19.1  One writer expresses concern that the 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).  She recommends listing the other criteria used in the Vision for Change  to define Special Programs (i.e., services that are unlikely to be adequately served by a market-driven system and ones for which VHA has developed unique expertise and resources).		

Rationale:  See revised recommendation 1.14.

Comments:  1.19  Concern was expressed regarding the role the Blind Rehabilitation Service Regional Consultant will perform in the new organization.  Their current role is essentially one of oversight and review of the Visual Impairment Services Team Coordinator positions, both full and part time at VAMCs.  He questioned 'where and how do the Regional Consultants fit in?'
	    
Disapprove

Rationale:  It would be the role of the Director, BRS to negotiate this matter with the VISN directors.
	
Proposed Revision	
1.19.1 Revised	Consideration should be given to realignment of  the Women Veterans Program to Patient Care Services in the Primary Care Strategic Healthcare Group (SHG) at some time in the future.  A determination and timetable for such realignment should be made by the Chief Public Health and Environmental Hazards Officer in conjunction with the Chief Patient Care Services Officer and the leader of the Primary Care SHG. 

Action Office:  DUSH

Target Date: 9/30/96

Recommendation:
1.20 The existing Academic Programs, as outlined in the June 1995, Office of Academic Affairs Position Paper on Programs:  Background, Recommendations, and Rationale, should remain in the Office of Academic Affairs.

Action Required:  
1.20.1 Prior to VISN activation,  convene an Academic Affiliation Task Force to make recommendations to the USH regarding reorganization principles for affiliation partnerships, both at Headquarters and at VISNs.  Staffing levels for this office should be a part of this review.

Action Office: DUSH

Target Date: Nov. 15, 1995

Comments:  1.20.1  The AsCMD for Academic Affairs emphasized that there has already been substantive comment from a number of sources about the role of affiliations in the new organization.  Issues related to this matters are also being reviewed by the Special Medical Advisory Group (SMAG) at its August meeting.  For this reason, she disagrees with the action.  A recommendation is made to let the VISNs implement their work in patient care delivery, and a determination can be made at some later date regarding the usefulness of further Task Force deliberations. 	   

Disapprove

Rationale:  While we agree that Affiliations Management should remain in this Office, it is unclear if the reviews referenced included concomitant reviews of both function and staffing levels.  Therefore, we recommend that this matter be reviewed by a Task Force to include a field chairperson at the level of VISN or VAMC director as well as other field and HQ representation. 

Comments:  1.20  G.V. (Sonny) Montgomery  (Ranking Member of the CVA) commented regarding the consideration being given to decentralizing the physician residency and other education programs.  He notes concern for the apparent rationale given for the proposal, that the current system of allocating residency positions 'often has little relationship to (a facility's) manpower needs'.  He emphasizes that VA's residency and training programs should not, however, be simply local manpower supplements.  The programs serve a larger purpose.  He reminds us that 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,  and such a step would be inconsistent with VA's statutory responsibilities.  While this change might serve operational goals, the reorganization cannot be permitted to undermine a national mission.	

Disapprove

Rationale:  This Workgroup has made no recommendation which changes the residency and clinical training program management at the HQ level.  Issue should be addressed to VISN Activation Workgroup. 

Comments:  1.20  A VAMC Director noted his support for this organizational change commenting that it was good to focus this office on affiliations only.  The extensive work by this office in conjunction with VISNs and VAMCs will be needed to address the effect of the new VHA organization on existing agreements.  	   

Approve

Rationale:  Commentary consistent with report.

Comments:  1.20  One individual expressed concern with the premise and rationale provided in the HQ Restructuring Workgroup report for realigning employee education in HQ from the Office of Academic Affairs.  In this extensive commentary, it was emphasizes that in the past VHA has not devoted sufficient resources to the education and career development of its employees and noted that increasing the priority placed and the resources expended is the real goal.  The writer cautions that splitting Academic Affairs and creating a separate Office of Employee Education is not necessarily going to accomplish this goal.  The writer cites reasons to keep VHA's education elements together, and emphasizes that the issue at the local level is also resources available to support employee education.  It was also emphasizes that there is no discussion in any of the Reports of the impact the proposed separation of education activities at the HQ level will have for field facilities that have coordinated education administrations and physical and technological infrastructures.   The writer closes by noting that if VHA HQ separates trainee education from employee education, the local levels will most likely follow suit which may lead to increased fragmentation and duplication of resources. 	    

Disapprove

Rationale:  The premise of the realignment is to bring all employee education units together.
	
Proposed Revision		
1.20.1  Revised	Prior to VISN activation,  convene an Academic Affiliation Task Force to make recommendations to the USH regarding reorganization principles for affiliation partnerships, both at Headquarters and at VISNs.  Functions and staffing levels for the HQ office should be a part of this review.   As representatives of the end user,  the task force should be chaired by a VISN or VAMC director and include both field and HQ representatives.  The report regarding revised functions and HQ staffing levels should be submitted to the DUSH.

Action Office:  DUSH	

Target Date :  Nov. 15, 1995



Recommendation:
1.21    Library Services  and satellite TV should be organizationally moved to the Chief Information Officer (3 FTEE).

Action Required:  1.21.1	Realign Library Services and satellite TV to the CIO
	
Action Office:  Patient Care Service, Academic Affairs  	

Target Date :  Oct. 1, 1995

			
Comments:  1.21  One individual affirmed understanding of the concept that all information  should be under the CIO, but expressed concern that this small group of professional librarians will not receive the support and attention merited in a CIO organization which must preface focus on numerous other more pressing issues.  It is recommended to leave this group under Academic Affairs for the present, realizing that the CIO Office is pending organization. 	

Approve

Rationale:  We agree these functions should be moved; however, the realignment does not need to occur immediately.  The action date can be determined after the appointment of the new CIO.

Comments:  1.21  One writer noted that the staff numbers given to the Library and satellite TV Network Programs don't reflect actual FTEE assigned to these program in HQ or in the field. 		

Rationale:  This information will be clarified by the CIO at the time of realignment these functions.

Comments:  1.21  The Director of the National Media Development Center stated that virtually all activities described for Library Services and satellite TV are educational support in nature.  He expressed concern that placing this program under the CIO will create a need for unnecessary organizational reliance, coordination, and communication. 	    

Disapprove

Rationale:  Contemporary thinking regarding information technology includes these types of functions.  Clearly the realignment is in line with a move to the CIO given technological innovations in the use, storage,  and transmission of data.  An example is the use of Internet by Library Services.
			
	


Recommendation:
1.22   The Employee Education field units (Cooperative Health-Manpower Education Programs, Regional Medical Education Centers, etc.) should remain within VHA under a Chief Employee Education Officer who is aligned under the Deputy Under Secretary for Health (DUSH).  Media Production and Development, along with its associated National Media Development Centers, should also be organizationally moved and aligned with the Employee Education field units under a Chief Employee Education Officer.

Action Required:
1.22.1 	Realign Employee Eduation field units and Media Production and Development together with the field units in St. Louis, Cleveland, Washington, and Salt Lake City under the new Chief Employee Education Officer after that position is filled.	

Action Office:  DUSH 	

Target Date :  To be determined.

1.22.2  	Undertake a critical analysis of Media Production and Development to include contracting and staffing recommendations which should begin within 45 days of appointment of the Chief Employee Education Officer.	
Action Office:  DUSH 	

Target Date :  To be determined.

Comments:  1.22.2  Position Paper (dated 7/18) received from the Director National Media Development Cts.   The paper provides an overview of the NMDCs listing services, cost data, and staffing information. The paper asserts the need for and quality of NMDCs operations.  The paper further recommends that NMDCs (1) be established as system-wide assets and (2) available services be prioritized.	

Disapprove

Rationale:  No change in action is needed.  Paper should be provided to Chief Employee Education Officer to be considered as part of the critical analysis to be undertaken.

Coments:  1.22.1  The Director of the Washington National Media Development Center emphasizes the evolution of functions as the primary provider of communication programs and products.  Previous alignment to the Office of Academic Affairs has been inconsistent with the evolving mission, and it is believed that alignment within the Office of Employee Education will not improve access to the Washington NMDC as a system asset.  Alignment under the Chief Administrative Officer is recommended as the most efficient organizational design. 	

Disapprove

Rationale:  Noted.  

Comments:  1.22.2  The CHEP Directors comment that the existing system of education delivery could be realigned to better address the new needs of the VISNs as well as constituent staff.  They recommend a defined period of resource review and redistribution based on the findings of a "balanced cadre" of education specialists and VHA customers currently working within VHA.  The CHEP model for meeting educational needs deserves serious review regarding how it can be replicated within the VISN structure for the VAMCs who desire community-VHA partnerships for education. 		

Comments:  1.22  The AsCMD for Academic Affairs does not support the alignment of media functions under the Employee Education Officer.  Support for the concept of examining either contracting for media functions outside VA or setting up the NMDC units for that VHA clients can contract with them in a true service center concept was recommended.  Additionally, work with the OAA to establish the Service Centers as resources available to all VHA and all three VA agencies was suggested. 		

Rationale:  The recommended assesment will be done as part of the analysis after realignment ot the Office of Education.

Comments:  1.22 One writer inquirers 'will field units such as GRECCs that are mandated to provide employee education, and the funding to provide that education, be moved to the Chief Employee Education Office?' 

D isapprove

Rationale:  The GRECCs will remain in their current location.

Recommendation:
1.23   The movement of the Rehabilitation Research and Development (R&D) Programs to the Office of R&D, as noted in the Vision for Change,  should occur.  The integrity of the legislative mandates which demand full Rehabilitation R&D, must be monitored and protected.  

Action Required:  1.23.1	Complete the movement of the Rehabilitation R&D Program.
	
Action Office :  Patient Care Service
	
Target Date :  Oct. 1, 1995

Comments:  1.23  One writer emphasizes that this recommendation is so important, and emphasizes that a specific mechanism is needed to insure that Rehab. R&D initiatives are monitored and protected.	   

Approve

Rationale:  Commentary consistent with report.  No change in recommendation or action required.

Comments:  1.23  One VAMC Director emphasized the need for a strong national structure to support R&D.  He noted a steady erosion in financial and leaderhip support for this program.  He cautioned that R&D cannot remain viable if the VISNs are expected to absorb its financial impact while competing in the healthcare market.  He expressed concern that this report does not address this issue.	    

Disapprove

Rationale:  This issue is already being addressed by the DUSH apart from the reorganization effort.

Comments:  1.23  One writer commented that he concurred with Rehabilitation R&D fencing.		



Recommendation:
1.24  The VISN HQ Support Team should be a fully matrixed group of individuals.  Establish five VISN Headquarters Support Teams, each team supporting approximately 4 or 5 VISNs representing a broad spectrum of Headquarters product lines and staff offices.  The responsibility of these teams is to provide proactive, responsive support to the VISN Directors, field personnel, the Chief Operating Officer and the Chief Network Officer on the full-range of support activities that these individuals might require.  The team is responsible for providing the information or assistance directly; or for advising the requester how and where the support may be obtained; or for recommending the need for a policy decision, task force, legislative relief; etc. to the Chief Network Officer or to Headquarters program officials.  

Action Required:
1.24.1 *  Establish a VISN Headquarters Support Team Workgroup which consists of representatives from the various HQ activities that will be represented on the VISN HQ Support Teams.
	
Action Office :  Office of USH, CNO
	
Target Date :  Aug. 15, 1995

1.24.2   Develop a proposal by the VISN HQ Support Team Workgroup which expands the full VISN HQ Support Team proposal, identifies the final number of teams, assigns teams to VISNs, defines organizational representation required by the VISN grouping, and defines VISN support requirements needed to be provided by HQ organizations.
	
Action Office :  VISN HQ Support Team Workgoup

Target Date :  Sep. 15, 1995 

1.24.3   Headquarters activities will select the individuals to serve as members of the VISN HQ Support Teams.	

Action Office :  Office of USH,  Chief Network Officer	

Target Date :  Complete by Sep. 30, 1995

1.24.4  The VISN HQ Team Workgroup, in conjunction with program officials and the Office of the USH, will define roles, responsibilities for participation, and on going assignments of individuals identified as team members.
	
Action Office :  Office of USH, CNO  	

Target Date :  Sep. 30, 1995 

1.24.5  The VISN HQ Team Workgroup will establish team operating procedures and insure that communication links and official assignments are completed.
	
Action Office :  VISN HQ Team Workgroup  	

Target Date :  Oct. 15, 1995  

1.24.6  VISN HQ Support Teams will begin activity.	

Action Office :  Office of USH, CNO  
	
Target Date :  NTE Nov. 1, 1995 

Comments:  1.24  Several individuals (5) supported the philosophical intent of these teams.  However, they expressed concern with both the size and specific tasks charged to the team.  Concerns were expressed that the roles and number of staff would increase, placing an undue burden of reporting and other requirements on VISN offices and VAMCs.  	

Disapprove

Rationale:  These teams are viewed as staff support, not line authority.  No reporting could be imposed without approval of  CNO.

Comments:  1.24  Several writers (8) requested clarification regarding how these teams relate to the eleven support staff recommended by the VISN Activation Work Group. 
	
Approve

Rationale:  See attachment of Comparison and Discussion of both Group Proposals, Prepared by Chief Financial Officer.  

Comments:  1.24  One individual articulated support for the HQ Support Teams citing that this format would make more effective use of the knowledge and talent in HQ than the alternate organizational plan put forward under the VISN Activation Workgroup report. 
	
Approve

Rationale:  Commentary is consistent with report.   No change in recommendation/action required. 

Comment:  1.24 One individual expressed concern for the feasibility of the suggested new organization in view of the MAMOE levels expected for FY 1996.  This writer recommended the elimination of the VISN teams and associated HSS staff in the CNO office.  He defined a four-dimensional mission for HQ as external liaison and function outside VHA; support to the USH, DUSH, CNO, and other HQ offices; national program leadership; and VISN/field support.  Given the mission of HQ offices, he emphasized that there should be no need for a liaison function between VISN and health care facility staff and the HQ/Service center offices that support them.  (See also recommendation 1. 7).  This writer recommended the vertical integration of the Service Center staff (and all field-based staff outside the VISNs) with their associated program offices in HQ. 	

Disapprove

Rationale;  We strongly believe that there a need for a link and/or liaison function between HQ and the VISNs and VAMCS, particularly in view of the scope of the reorganization.  This may indeed be a transitional organizational model based on future budget constraints.

Comment:  1.24  One writer noted that the proposed reorganization of HQ, including current staff, perpetuates the separation of clinical managers and health systems/financial managers.  The only exception is in the VISN Support Team component.  This commentary cites a 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 and the health system manager's perspective resulted in recommendations that were both patient-centered and cost effective.	

Approve

Rationale:  Commentary is consistent with report.   No change in recommendation/action required. 

Comments:  1.24  One VAMC Director expressed concern with the size and organization of the HQ VISN Support Teams.  She notes that this recommendation establishes five interdisciplinary teams, totaling 70 FTE for VISN support.  Concerns range from (1) the insertion of a layer between program offices and the VISNs and the field, (2) the structure appears a variation on current Regions field staff office structure, (3) the accountability of staff to the VISN is unclear, to (4) redundancy of current HQ organization if HQ is functioning as it should.  This writer also emphasized that this proposal does not correlate with the VISN Activation Workgroup proposal. 

Disapprove

Rationale:  The HQ VISN Support Teams do not involve 70 FTEE.   Actual headcount may be 70 persons (5 teams with up to 14 individuals), but FTEE is a fractional equivalent less than 20.   These individuals only spend a small part of their work week in team activities and are staff to the various administrative program offices and SHGs .  In response to the concerns raised (1) teams have no line authority over VISNs and provide an opportunity for support and consultative HQ service; (2) no similarity to Regions, as this organization is a product line support focus versus function focus; and (3) VISN directors, through the CNO, will provide feedback  to HQ program officials on quality of support to VISNs aided by  team performance objectives to address accountability.  Differences with the VISN Activation Workgroup proposal were presented to the Coordinating Committee on 08/29/95.  

Comments:  1.24  One physician recommended that 'the VISN support teams may well be best utilized as a transitional group which has a fixed time for operations with a defined point of re-evaluation.  The review should determine if the HQ functions for VISN support are operating to meet expectations.	   

Approve

Rationale:  The concept of a formal process for re-evaluation is essential  for all aspects of the reorganization.  Action 1.24.4 has been revised and Action 1.24.7 added to reflect the need for re-evaluation.

Comments:  1.24  One group of employees emphasized that the VISN HQ Support Teams were the least clearly described component of this report.  They noted that this team structure merely replaces the Regional structures that were previously in Central Office, adding that these structures were difficult to work with and should not be duplicated.  This group emphasized also that this appeared another level of the bureaucracy and without definitive clarification of its purpose, they saw no need for them. 	   

Disapprove

Rationale:  New  team concept developed is not viewed as a replacement of the Regional structure which did not work well.  This model provides an organized means to facilitate communications and staff support to VISNs by HQ staff.

Comments:  1.24  The Director, National Veterans Service of the VFW also emphasized that it was unclear as to the real function of the VISN HQ support teams.  He questioned whether  'this was a return to the former area office concept, thereby creating another administrative layer?'
	   
Disapprove

Rationale:  New  team concept developed is not viewed as a return to the former area office concept which did not work well.  This model provides an organized means to facilitate communications and staff support to VISNs by HQ staff.

Comments:  1.24	One writer made extensive comments generally supportive, noting that the 'sole purpose of the teams was to support line management (i.e., the VISN Directors).'  This individual suggested that this team approach with collaboration between clincal and operational mangers should be evaluated as a potential model for all of HQ.  A concern was expressed that these teams could create another 'layer' between the Healthcare Program, Support Programs, Office of PPP in HQ, and the field. 
	    
Approve

Rationale:   Commentary is consistent with report. Intent of model is to focus on integrative support roles.   Operations contrary to the objectives and desired paradigms will be monitored and adjustments made as teams are re-evaluated.
Comments:  1.24  Several writers (3) commented on the numbers of meetings (i.e., Team Meetings, CNO Meetings, and Program Office Meetings) referenced within the proposal.  Although noting these meetings as good methods to enhance communication, a concern was expressed that a significant number of HQ staff could be spending remendous numbers of hours in meetings.  

Rationale:  New virtual organization concept will minimize face-to-face meetings.  Techological updates to facilitate scheduling include (1) recent installation of computer assisted scheduling throughout HQ and (2)pursuit of availability of LOTUS Notes for all HQ staff.

Comment:  1.24.4 The Director, Emergency Medical Preparedness Office recommended that membership on the VISN Support Teams include a designated member of the EMPO staff.  He adds that since EMPO is located in Martinsburg, WV, arrangements can be made for actual present in HQ as necessary to meet support requirements. 
	
Approve

Rationale:  Participation of other staff expertise beyond those given as examples in the model will be solicited by the VISN teams as required.

Comments:  1.24  One writer expressed concern regarding the requirement that VISN directors formally evaluate the teams periodically.  This writer emphasized that there should be  clear responsibility for the development of these performance factors that are specific and measurable.	    

Approve

Rationale:  Commentary is consistent with Workgroup deliberations.  Factors for assessment of team effectiveness to be determined, see revised 1.24.4.

Proposed Revision:
1.24.4 Revised The VISN HQ Support Team Workgroup, in conjunction with program officials and the Office of the USH, will define roles, responsibilities for participation, methods for assuring team as well as individual member evaluation, and on going assignments of individuals identified as team members.

Action Office: Office of USH, CNO

Target Date: Sept. 30, 1995

1.24.7 Addition The VISN HQ Support Teams will be re-evaluated for effectiveness in meeting the functional objectives stated.  The VISN Headquarters Support Team Workgroup performing this assessment will be chaired by a VISN director and include both HQ program officials and field representation at the level of VISN and VAMC directors.  The report will include recommendations regarding continuation of this model and be submitted to the DUSH, through the CNO. 

Action Office: Office of USH, CNO

Target Date: June 30, 1996

			

SUPPORT PROGRAMS
General  Comments:	
One writer expressed concern for the feasibility of the suggested new organization in view of the MAMOE levels expected for FY 1996.  The commentary recommends elimination of the Chief Administrative Officer (CAO) organization and reassignment of CAO functions as follows:  (1) Management & Admin. Support to COS, (2) Volunteer Programs to COS to integrate with VSO Liaison, (3) VA/DoD Medical Sharing to Chief Affiliations Officer, (4) Environmental Management Service to Construction Management (changing name to Facilities & Construction Mgt.), (5) Health Administation Service to the CIO, and (6) the A&MM Liaison to the CFO.  
	
Disapprove

Rationale:  Would fragment program; would not yield significant FTE savings.

Comments:One writer recommended that the Canteen Service might be better aligned under the Chief Administration Officer in the Office of Administration. 
	  
Disapprove

Rationale:  VHA not given authority to determine location of this program.

Comments:  The General Counsel (GC) expressed concern regarding issues on which she believed the HQ report did not adequately address.   These include both (1) contracting and construction law issues and (2) information law issues.  She emphasizes the need to assure involvement and representation of Office of General Counsel  in future working group0s to help identify and address both contracting and information law issues at the earliest possible time.   The presence of GC staff will also facilitate assistance needed to develop legislative initiatives to accomplish objectives identified for the new VHA organization.
	   
Approve

Rationale:  As appropriate, General Counsel will be suggested for membership to workgroups and/or task forces recommended that address these issues of concern.


Recommendation:
1.25  Emergency Medical Preparedness Office (EMPO).  VHA should evaluate VA's role and responsibilities in fulfilling the mandated DoD backup mission and make a decision on the appropriate level of VHA involvement in non-mandated functions performed based on the level of limited resources presently available.
	
Action Required:	
1.25.1  	The DUSH will  convene a Task Force to evaluate the Emergency Medical Preparedness Office (EMPO) roles and responsibilities.   Task the Chief Emergency Medical Preparedness Officer to recommend members of the multi organization and/or disciplinary team, and assign  a field based chairperson.
	
Action Office :  USH
	
Target Date :  Convene NTE Sep. 30, 1995


1.25.2   The Task Force will prepare a final report with recommendations for  downsizing and/or streamlining operations to the DUSH.	

Action Office :  Designated Task Force
	
Target Date :  By Nov. 15, 1995.

Comments:  In the discussion of the future role of EMPO, several writers (3) commented that the long term strategy is not clear of either retaining and downsizing EMPO or moving it to DoD or FEMA.

Approve

Rationale:  This comment is consistent with the report.  The recommendation addresses a strategy for review of the functions and staffing related to EMPO.

Comments:  1.25  One commenter recommended that DVAs role in providing disaster medical emergency services should be eliminated resulting in a reduction of FTEE.  This permits the DoD to reassume their former role for this function.	

Approve

Rationale:  The current recommendation and action addresses this concern.

Comments:  1.25  The Director, EMPO provided comments in the form of a position paper to clarify functions associated with this office.  In addition to a clarification of functions, the information emphasized that streamlining of operations has already been proposed and EMPO will utilize the review process to make further recommendation to the DUSH.  Corrections were cited to the organizational chart included in the workgroup report as 'National Programs' and 'Response Support' being the correct titles for the blocks shown under the Chief EMPO. 	   

Approve

Rationale:  The changes noted will be reflected in the final organization chart for HQ.
	
Proposed Revision		
1.25 Revised  Emergency Medical Preparedness Office (EMPO).  VHA should evaluate VA's role and responsibilities in fulfilling the DoD backup mission and make  decisions on the appropriate level of VHA involvement in non-mandated functions performed based on the level of resources available for support of this mission.
		
1.25.1  Revised	The DUSH will  convene a Task Force to evaluate the Emergency Medical Preparedness Office (EMPO) roles and responsibilities.   Task the Chief Emergency Medical Preparedness Officer to recommend members of the multi organization and/or disciplinary team, and assign  a field based chairperson at the level of a 

Action Office :  VISN or VAMC director.
	
Target Date :  USH
	
Convene NTE Sep. 30, 1995



Recommendation:
1.26  VA/DoD and Medical Sharing Office.  Continue the decentralization of authority for  sharing of specialized medical resources and scarce medical specialists to the VISNs with medical center accountability delineated in performance measures.  This oversight function is established as a part of overall Department oversight of contracts, and as a result of VA medical centers identified in non-compliance with external review regulations.

Action Required		
1.26.1	
Prepare appropriate performance elements for VISN directors to ensure VAMC level accountability regarding program management of specialized medical resources and scarce medical specialists.
	
Action Office :  Support Services, Sharing Office
	
Target Date :  Complete by Oct. 1, 1995

1.26.2  	
Task the Director, VA/DoD and Medical Sharing with recommending members of a multi-level (HQ, VISN, VAMC) and multi-disciplinary team to evaluate the decentralization of oversight to the lowest organizational level possible.	

Action Office :  DUSH
	
Target Date :  Complete by Sep. 30, 1995

Comments:  1.26  The Office of Acquisition & Materiel Mgt (OA&MM) comments that this recommendation is unnecessary as the Medical Sharing Office is already transitioning from a largely review function to a consultative resource for VHA.  As VHA moves to new clinical service contracts, OA&MM believes it would be a significant mistake to lose the program and acquisition related expertise of the Medical Sharing Office.  While this office supports accountability at all organizational levels, it believes VISN Directors should have the role of ensuring this type of statutory/program compliance.  OA&MM disagees with the assumption that no oversight is necessary.  OA&MM believes strongly that the USH should be fully briefed on the major issues, including Congressional concerns, before approving this recommendation. 	   

Disapprove

Rationale:  We disagree that the recommendation is unnecessary, and emphasize that it is intended to spur review of HQ functions associated with decentralization of this process.

Comments:  1.26  The Director Medical Sharing Office expresses concerns regarding a premise of lessening oversight.  He emphasizes that VHA has delegated approval of competitive specialized medical resource sharing and scarce medical specialist services contrats of up to $1.5 million to the VAMCs, and notes that two further major delgations are planned.  He emphasizes the ongoing need for policy formulation and technical assistance at the National level to include continued liaison with Offices of General Counsel, Acquisition & Materiel Management, and Clinical Programs.   The writer did express concern that the VISN director may be far too high a level for performance measures dealing with adherence to specialized medical resource and scarce medical specialist services program management.  	   

Approve

Rationale:  Commentary is consistent with overall report objectives, and the writer emphasizes that the Office is amidst pending threshold changes.

Comments:  1.26  One writer expresses concern that the assumption that no oversight would be required of medical centers creating contracts for specialized medical resources since medical centers are to be held accountable for following the mandates of the law  is not completely accurate.  The writer emphasizes that the oversight function was established as a result of non compliance, and a more appropriate assumption might be that oversight of a different type may be appropriate.  The writer suggests rather than continuing the current review and approval of every sharing contract by the HQ sharing office, an alternative form of oversight may be employed such as comparing the projected revenues and workload used to initially justify the purchase of specialized medical equipment or to justify the need for the contract with actual recoveries or workload reimbursements.  The writer adds that performance against contract should provide the necessary information to signal the need for more in-depth review and oversight by external organizations.  		

Rationale:  Noted.  Alternative forms of oversight need to be decentralized to local or VISNs wherever feasible.
	
Proposed Revision		
1.26.2  Revised 	
Task the Director, VA/DoD and Medical Sharing with recommending members of a multi-level (HQ, VISN, VAMC) and multi-disciplinary team to evaluate the decentralization of oversight to the lowest organizational level possible.   	

Action Office :  DUSH
	
Target Date:  Complete by Sep. 30, 1995


Recommendation:
1.27  Voluntary Services restructuring should follow the well-defined mission as stated in thVision for Change

Action Required: 1.27.0 None.  No organizational changes recommended.

Comments:  1.27 One writer recommends moving this office under the Chief Patient Care Services Officer since Voluntary Service primarily supports VHA's clinical Services.

Approve

Rationale:  Consideration of realignment of this service was discussed by the Workgroup, and determined to be an issue that should be pursued at a future time.   Various scenarios for realignment were considered, and it was recommended that the CAO be tasked with future assessment of this matter.  See revised action.

Proposed Revision
1.27.1 Addition No organizational changes recommended at this time.  The DUSH should task the CAO with review of the organizational alignment of Voluntary Service within the new HQ organization.

Action Office: DUSH

Target Date: To be determined

Recommendation:
1.28   Management and Administration Support Office (MASO).  Create a new HQ administration function, the Management and Administration Support Office (MASO), for overall administrative support of the internal operation of VHA headquarters.

Action Required:  
1.28.1  Realign the Health Care Staff Development and Retention Office within the current Management Support Office. 

Action Office: DUSH

Target Date: Oct. 1, 1995

1.28.2  Task the Chief Administrative Officer to recommend members of a multi organization/disciplinary team to evaluate VHA needs for healthcare retention and development, both program staff and distributed FTEE for such programs.

Action Office: DUSH

Target Date: Oct. 1, 1995

1.28.3  The Task Force will complete a final report/recommendations for the DUSH

Action Office: Support Service, Chief Administrative Officer

Target Date: Nov. 15, 1995

1.28.4    The DUSH will task the Chief Administrative Officer and the Chief Construction Management Officer with recommending members of a multi-orgnization/disciplinary team to evaluate VHA needs for a consolidated office support function.  Realignment includes transfer of three staff from the Administrative Support Office located within the Office of the USH.

Action Office: DUSH

Target Date: Final Report NTE Dec. 1, 1995

Comment:  1.28  The Deputy Asst. Secretary for Financial Management requested clarification of the responsibility that MASO will have for VHA-wide Human Resources Management (HRM) policy and procedures.   It is difficult to infer whether the staff support to be provided by this office includes policy development or other HRM functions.   The establishment of this type of function/liaison in VHA is consistent with VBA's approach and would facilitate the internal coordination and implementation. within VHA of VHA-wide personnel and personnel system issues.   	  

Disapprove

Rationale:  Functions proposed are same as those performed in current organization.  Additional FTE not available to assume the global range of functions analogous to the VBA approach which are suggested.

Comment:  1.28  The AsCMD for Construction Management (CM) supports the greater sharing of its administrative support capabilities to provide broader support to VHA.  However, he emphasizes that a consolidated HQ administrative support function does not have merit when those being supported are located in different buildings.  He adds that the Office and Library Support Division in CM is the single point of contact for a broad range of essential support functions that extend beyond 'administrative support'.   This writer believes that CM currently provides these support services to all VHA employees in the Lafayette Building and can continue to do so in the new organization.	    

Disapprove

Rationale:  As VHA restructuring evolves, the total number of employees needed is assumed to be less than the current number assigned.  Consolidation of support functions makes good sense in this new environment and separate geographic locations is not viewed as a hindrance to this objective.  The current Management Support Office, located in Tech World, does provide support to various HQ offices in physically separate locations.

Comments:  1.28.1  One writer expressed concern that the location of the Health Care Staff Development & Rentention Office (HSD&R) in the Management & Administration Office (MASO) appears to be in conflict with the location of Employee Education to the Deputy Under Secretary for Health.  This writer notes that staff development often (usually) means training and/or education.	   

Disapprove

Rationale:  The report clearly notes that the focus of HSD&R was recruitment and retention, not employee education.  Thus, alignment with other human resources functions and expertise to the MASO appears appropriate. 

Recommendation:
1.29    Realign the Chief of Staff selection process and the credentialling of headquarters Title 38 personnel from the Office of the USH to the Management and Administrative Support Office.

Action Required: 1.29.1  Realign this function and reassign 2.0 FTEE formerly part of the Professional Affairs Staff to MASO.

Action Office: DUSH

Target Date: Oct. 1, 1995

Comments: 1.29.1  One commentary strongly recommends staff with clinical expertise in Health Care Staff Development and Rentention Office, including at least one MD to be responsible for COS selection and credentialing and Title 38 issues.

Disapprove

Rationale :  Not required at HQ level due to recent delegations of this authority to the field.

Recommendation:
1.30    Establish a A&MM Liaison position the SES level and provide appropriate staff support within the Office of the Chief Administrative Officer.  The position needs to be at the SES level to represent the VHA in the most effective manner in communicating and addressing VHA issues with Department acquisition officials.

Action Required:  1.30.1 Establish and staff the A&MMS liaison position as soon as possible.

Action Office:  DUSH

Target Date: NTE Nov. 1, 1995

Comments:  1.30  One writer questioned the need to establish an SES position in VHA for this function.  Currently, the Office of A&MM, which includes the National Acquisition Ctr in Hines, provides this service to VHA.  Thus, the establishment of this liaison position in VHA is viewed as a duplication of functions that already exist within VA.	

Disapprove

Rationale:  There has not been a focal point within VHA to develop, coordinate and monitor initiatives which could better assert the strength of VHA in the marketplace.  VHA has not always received the best bang for our buck in the contracting for, acquisition of, and distribution of goods and services.  Secondly, one of the responsibilities will be to review current internal processes by which goods and services are actually made available to VHA customers and make recommendations to streamline & improve these processes.  This new function serves a much needed Management purpose and, in an organization expending over $4 billion annually for goods and services along, has great potential to make the health care system more responsive and efficient. 

Comments:  1.30  O&MM strongly supports establishment of this position under the CAO.  The position will facilitate day-to-day issues, improve service delivery, and assist with contemplated changes. 	

Approve

Rationale:  Comment consistent with report, no change required. 

Comments:  1.30  The Dirctor of EMS in HQ comments that the A-76 HQ responsibility/function (policy/scheduling/appeals process, liaison with OMB and 008) was not specifically referenced within the workgroup report.  He recommends that such an assignment would be appropriate for inclusion within the scope of the A&MM Liaison Organization. 	    

Approve

Rationale:  The workgroup concurs that this suggestion has merit, and will refer it to the Chief Administrative Officer for consideration as a function for inclusion as a responsibility of the A&MMS Liaison.


Recommendation:
1.31    Task the new A&MM Liaison with development of a position paper to move the Supply, Processing and Distribution (SPD) function from the Department's Deputy Assistant Secretary for Acquisition to VHA, Patient Care Services, defining the HQ role, if any, and functions of such a group.

Action Required:  1.31.1  Submit the SPD position paper to the DUSH through the Chief Administrative Officer.	

Action Office:  A&MM Liaison
	
Target Date :  Dec. 1, 1995

Comments: 1.31  OA&MM recommends that the A&MM Liaison  be tasked with the responsibility to write a position paper on the appropriate organizational placement of the SPD Program rather than in support of a predetermined outcome.

Approve

Rationale:  See revised action 1.31.1 below.

Comments: 1.31  The Director EMS in HQ recommends the alignment of the SPD function within the Facilities Management Program (FMP) Office.  He notes in his extensive commentary functions and an historically prospective of this program, its initial alignment with Surgical Service  and its current incorporation into EMS.  He emphasizes that alignment with FMP will facilitate the review of program functions to determine deletion of redundancies and appropriate centralization/decentralization issues.

Disapprove

Rationale: The workgroup believes that this realignment should receive further review prior to a definitive determination of placement being made.  See revised action.

Proposed Revision
1.31.1 Revised The new A&MM Liaison will develop a position paper that considers the most efficient and effective organiztional placement of the SPD function in the VHA organization.  The paper will be submitted through the Chief Administrative Officer to the DUSH.

Action Office :  A&MM Liaison

Target Date :  Dec. 1, 1995


Recommendation:
1.32   Realign Engineering Management and Field Support Office (EMFSO), except for Non-Recurring Maintenance (NRM) and Environmental Engineering, within the Office of Construction Management rather than with Environment Management Service (EMS).

Action Required:
1.32.1  Move EMFSO to the Chief Construction Management Officer (CCMO)
	
Action Office CCMO
	
Target Date Oct. 1, 1995

1.32.2  The CCMO will  recommend members of a task force, including a field chairperson.  This task force will analyze these EMFSO functions to include (a) those that should remain in Headquarters, (b) those which could be performed at the Support Service level, and (c) those that should be eliminated.  This report with recommendations, including FTEE deployment should be provided to the DUSH.  The analysis should be in the context of the current and future CMO structure.  For example, the remaining sections of EMFSO, to include Plant Technology and Safety Management Services, and Fire Protection could be abolished at HQ level and functions transferred to the VISN Service Support Centers (VSSO).    See also recommendation 1.41.2.
	
Action Office CMO
	
Target Date Jan. 12, 1996

Comments:  1.32.2  The Regional Safety Advisory Council (RSAC) notes that the creation of the Plant, Technology and Safety Management (PTSM) Service and Fire Protection resulted from the reorganization of the Office of Facilities.   The RSAC expresses concern regarding the visibility of PTSM within HQ.  This group believes that the suggestion to abolish PTSM and Fire Protection sections at the HQ level and transfer these functions to the VISN level is regressive and does not build upon past program successes.  They also express concern that decentralizing the Fire Protection Program will result in significant loss of  program status with JCAHO.  The RSAC adds that the VA was found deficient in the last three OSHA evaluations, and proposed changes are not in compliance with EO 12196 as well as OSHA Regulations.		

Rationale:  The recommendation and report support review of these functions for alignment in the new VHA organization.
Comments:  1.32  One writer comments that Construction, Operation, Safety, and Environmental Engineering (EPA) should be maintained as a unit to effectively support VAMCs and provide a technical resource to respond to Congress and the various regulatory agencies.  He believes a national office is needed to interpret regulations for  the VAMCs and to provide consistency across VHA. This writer emphasizes that the division of EMFSO will make it difficult to provide field support and not have duplicate policy and solutions.	  

Approve

Rationale:  Commentary is consistent with objectives of report.  See revised recommendation 1.32 regarding division of EMFSO.

Comments:  1.32  The Assistant Secretary for Human Resources and Administration comments that 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 emphasize that the reports did not address ongoing safety and health responsibililities, and expressed concern about how this program will be managed in the new VHA.  He notes it is important to include safety and health roles as VHA continues to develop organizational plans.
	   
Approve

Rationale:  Occupational Safety and Health has been addressed within this report.

Comments:  1.32  One VAMC Engineering Officer comments that the trend at VAMCs is to combine services with EMS and Engineering being a logical grouping.  In this respect the HQ alignment should reflect the field reality.  He emphasizes the relocation of functions now provided by the EMFSO should be made with input from the engineers (customers) at VHA facilities.  Currently EMFSO provides a single point of contact for resolution of issues which involve multiple disciplines, and having them in one location and talking to each other works well.  Whether they are a single entity or part of a larger group does not matter.  They should be placed such that their allegiance is to VHA, the same as the field staff they support. 	   

A pprove

Rationale:  Comment is consistent with report.  See revised recommendation 1.32 below regarding division of EMFSO.

Comments:  1.32  Commentaries (3) recommended  a critical analysis prior to any decisions being made regarding this realignment.  One writer emphasized that it is important to validate whether any or all of the function currently performed by EMFSO are needed, and if so where they can be best be aligned. 	 

Approve

Rationale:  Comment is consistent with action recommended.

Comments:  1.32  One Engineer wrote a detailed commentary noting his full agreement with the Vision for Change  and the delegation of the decision making to the lowest possible levels to empower talented managers to manage the complete process.  This writer provides a proposal  to join the resources of all facility management into one organization structure.  He emphasizes the need to stop the turf conscious management practices currently evident, and encourages that we not centralize the delegated construction or the environmental and engineering technical support services.  He cautions that the proposed joining of OCM, EMFSO, and EM would only become operational if it is structured effectively.  He closes by encouraging that a structure be formed that fully supports the VISN and VAMC operational needs.	  

Approve

Rationale:  Comment is consistent with report objectives.

Comments:  1.32.2  Construction Management  (CM) recommends that the Fire Protection portions  (functions and staff) of the EMFSO be retained in HQ and assigned to the Consulting Support Office within CM.  CM notes that over 200 requests (a 15% increase from 1994) from VAMCs for assistance has been received since October 1995. 
 		
Rationale:  This will be addressed by the Task Force review recommended in action 1.32.2.

Comments:  1.32.2  One writer strongly recommends that the VA safety and industrial hygiene programs functionality remain intact.  Administrative alignment of this program should be developed with active participation of the safety and industrial hygiene staff from the VAMCs, Regions, and VHA headquarters. 

Rationale:  See revised recommendation 1.32.

Comments:  1.32.2  One writer recommends that all safety functions currently assigned to EMFSO remain together at VHA HQ, including the Environmental Engineering Division.  Since the overwhelming majority of environmental requirements must be accomplished by VAMC Engineering and Safety staff, the Environmental Engineering Division should remain with EMFSO. 
 	   
Approve

Rationale:  See revised recommendation 1.32.

Comments:  1.32  The Director Environmental Management Service (EMS) recommends the realignment of the remaining EMFSO function to CM to provide appropriate assignment of the majority of like functions.  The CM organization provides the proper expertise to further develop these functions, with the exception of Plant Technology,  Safety Management Operations, and Biomedical support programs.  Some of these programs, not closely related to the construction process, are recommended for joint review by the Chief Administration Officer (CAO) and Facilities Management Officer (FMO) to determine their proper role and future assignment for completion NTE 1/12/96.  The Director EMS notes that some of these programs might appropriately be reassigned to the Facilities Management Program, and remaining functions to either the FMO HQ, the field or VISN Service Centers.	   

Approve

Rationale:  See revised recommendation 1.32.

Comments:  1.32  One Chief Engineer noted that the reorganization of EMS and Engineering into a Facilities Management Group has merit. He emphasized that this reorganization was consistent with what he has seen in the private sector.  He expressed a concern that Engineering and EMS not loose their identities in their specialty areas, as each needed to remain experts for the VAMC directors.  He also suggested that Police and Dietietics may be other probable candidates to bring into this group as well, and noted that in the private sector this merged alignment was working well.  		

Rationale:  Commentary has merit, and overall objectives are consistent with reorganization efforts.  

Comments:  1.32  One Chief Engineer emphasizes that he does not agree with the recommendation not to combine EMFSO and EMS.  He recommends strongly that they should be combined in their entirely at the HQ level.  Breaking EMFSO up and moving responsibilities to different locations can only provide fragmented support for Engineering Services at VAMCs.  Not consolidating will only make the already present conflict worse and create friction between sections for those VAMCs where EMS and Engineering have consolidated.  He emphasizes that a single point in HQ that can provide consistant guidance on shared issues is the best way to go. 		See revised recommendation 1.32.
	
Proposed Revision		
1.32 Revised  Realign Engineering Management and Field Support Office (EMFSO), except for Non-Recurring Maintenance (NRM), within the Office of Construction Management.
	
1.32.2 Revised	The CCMO will  recommend members of a task force representative of HQ and the field, including a field chairperson  that is a VISN or VAMC director.  This task force will analyze these EMFSO functions to include (a) those that should remain in Headquarters, (b) those which could be performed at the Support Service level, and (c) those that should be eliminated.  This report with recommendations, including FTEE deployment should be provided to the DUSH.  The analysis should be in the context of the current and future CMO structure.  For example, the remaining sections of EMFSO, to include Environmental Management, Plant Technology and Safety Management Services, and Fire Protection could be reduced at HQ level and significant functions transferred to the VISN Service Support Centers (VSSO) or to VAMCs.    See also recommendation 1.41.2.
	
Action Office :  CMO
	
Target Date :  Jan. 12, 1996


1.33   Relocate the NRM program and functions to the VISNs to allow for less interruption in project design, improved planning, and increased local accountability.

Action Required :  1.33.1  Delegate the NRM program to the VISNs.
	
Action Office :  CMO	

Target Date :  Apr. 1, 1996

Comments: One Engineering Officer comments that moving the NRM program to the VISN level should prove beneficial to the VAMCs.  He also recommends consideration of movement of the Minor Construction program to the VISN level and not to CM.

One writer comments that the NRM program should be consolidated with CM rather than relocating it to the VISNs.  CM will delegate the management of the NRM and the minor programs to the VISNs.  However, some HQ oversight/roll-up functions such as budget, operating plan, prioritization of project categories (i.e., asbestos abatement), are necessary for required top management and Congressional reports.  These functions would best be accomplished within CM and is consistent with consolidating all construction function in one office as a single point of contact within VA.

Approve

Rationale: Commentary is consistent with current recommendation.

Comments: Several comments (4) received in support of this recommendation.  One writer suggests that the delegation be taken another step by delegating operational responsibility for all construction of 25 million and less (major, minor misc, and NRM) to the VISN level.

Rationale: Commentary is reflective of current recommendation.

Recommendation:
1.34    Relocate Environmental Engineering in HQ to Environmental Management Service (EMS).

Action Required:
1.34.1  Transfer the Environmental Engineering Unit of 3.0 FTEE to EMS.

Action Office :  MASO

Target Date Oct. 1, 1995

1.34.2   Task the Chief Administrative Officer (CAO) with reviewing the appropriate functions and location of EMS staff.

Action Office:  CAO

Target Date :  Jan. 12, 1996

Comments:  1.34  The Chief Engineers Advisory Board (CEAB) believes that there is not firm rationale for this relocation of Environmental Engineering, emphasizing that the professionals that reside with EMFSO do not have the ability to easily interface with their peers.  The commentary emphasizes that Environmental Engineering encompasses a wide range of complex regulatory issues, and note that the splitting off of this function could lead to communication and compliance problems.  Several comments (5) received also were not in agreement with the relocation of Environment Engineering.  	  

Approve

Rationale:  Concur with proposal that Environmental Engineering should remain intact with other EMFSO functions.  Recommendation 1.32 is revised to move this function with EMFSO to Construction Management, and see revised recommendation 1.34 below and action 1.34.1 which is deleted.

Comments:  1.34  The Regional Safety Advisory Council (RSAC) expressed concerns regarding relocation of this program to EMS.  With the exception of the hazardous materials and waste management functions, the RSAC emphasizes that these programs have little in common and express concern that the integrity established with regulatory agencies may be jeopardized.  As an alternative, the RSAC suggests placement under Construction Management as CM handles more diverse and complex environmental issues than EMS. 	  	

See rationale for comment above.

Comments:  1.34.1  The Director EMS supports this proposal, as an appropriate step in the direction of creating a customer focused, field supporting, and coordinated integrated waste management program. 

Disapprove

Rationale:  See revised recommendation 1.34 which deletes action to realign this function with EMS.

Proposed Revision:
1.34  Delete  Delete Recommendation:  Relocate Environmental Engineering in HQ to Environmental Management Service (EMS).		

1.34.1  Delete  Delete Action:  Transfer the Environmental Engineering Unit to EMS.		

1.34.2  Revised	Task the Chief Administrative Officer (CAO) with performing a critical analysis of the appropriate functions and location of EMS staff.  This analysis should include (a) those functions that should remain in Headquarters, (b) those which could be performed at the Support Service level, and (c) those that should be eliminated.  
	 
Action Office :  CAO	

Target Date :  Jan. 12, 1996


Recommendation:
1.35  Review the Engineering Service Center (14 FTEE) in St. Louis for continued need whether in total or in part.

Action Required:
1.35.1	The Chief Construction Management Officer (CCMO) will recommend members of a task group, including a field chairperson, to perform a critical analysis of the Engineering Service Center in St. Louis.   (See also recommendation 1.40.2.c.)
	
Action Office :  CCMO	

Target Date : Oct. 1, 1995

1.35.2  	The task group report with recommendations will be provided through the CCMO to the DUSH.	

Action Office :  CCMO

Target Date :  Jan. 12, 1995

Comments:  
The Chiefs Engineering Advisory Board (CEAB) emphasizes the productive and cost effective operation of the Engineering Service Ctr.  The commentary acknowledges that a review may be required,  and supports continued operation of the center citing many reasons.  The CEAB and requests representation on the task group selected to do this review.   Other comments (4) received from Engineer Officers at various VAMCs request representation in any deliberative process or task force reviewing this issue.


The Director of the VA National Engineering Service Center (NESC) at St. Louis recommends deletion of this action item.  He cites that the Deputy Under Secretary for Health for Administration and Operations ordered an onsite critical review in 3/93.  Reviews were completed in 4/93, 8/94, and again by the Board of Directors in 4/95.  It is recommended that HQ formalize the reporting process of this Board and solicit the Board's advice and recommendations when making decision regarding the Center.   Comments provided by the Regional Safety Advisory Council also noted existence of the Board and completion of a critical review approximately two years ago.

Several Chief Engineers (3) comment on the cost effective service received in the past that has made the Biomedical Programs so successful.  They encourage the continuation of this function regardless of where the Engineering Service Center is positioned in the organization.  

Approve

Rationale: See revision of recommendation 1.35 and actions 1.35.1 and 1.35.2.

Proposed Revision:  1.35 Revised  Review the Engineering Service Center (14 FTEE) in St. Louis for continued need whether in total or in part.  This review should be made as part of other reviews of out-placed Headquarters programs (i.e. 'off the top' programs).	

Action Office :  DUSH	
Target Date :  To be determined

1.35.1 Delete  Delete Action:  The Chief  Construction Management Officer will recommend members of a task group, including a field chairperson, to perform a critical analysis of the Engineering Service Center in St. Louis.		

1.35.2 Delete  Delete Action:  The task group with recommendation will be provided through the CCMO to the DUSH.		
Recommendation:
1.36  Organizationally realign the Engineering Training Center (15.5 FTEE) in Little Rock to the Office of Employee Education and Training in VHA.

Action Required  1.36.1  Realign the Engineering Training Center (15.5 FTEE) to the newly created Office of Employee Education and Training aligned under the DUSH.   
	
Action Office :  Office of Employee Education and Training	

Target Date :  Oct. 1, 1995

Comments:  1.36  The Chief Engineers Advisory Board (CEAB ) believes that this organizational realignment does not support the increasing needs to provide technical and targeted training to employees.  The CEAB feels that this function should remain with EMFSO, even if it is moved to CMO as this group also uses the ETC for training activities.	   

Disapprove

Rationale:  This function will be retained after an organizational realignment to the Office of Employee Education.  

Comments:  1.36  The Director Education & Trng Ctr for Engineering & Construction Mgt comments that organizationally aligning the Engineering Center to the Office of Employee Education makes sense if all VHA training functions are assigned to this office to facilitate the efficient coordination of resources.  He emphasizes that the function of the Engineering Center should be maintained to use the existing staff and resources developed.  Much training delivered by the Center is not available otherwise, especially in the cost effective modes utilized.	   

Approve

Rationale:  Consistent with report objectives.

Comments:  1.36  Several comments from VAMC Engineers (5) noted the outstanding performance of this organization, and expressed concern about attention being lost to Engineers if this organization is aligned under the Chief Employee Education Officer. 	   

Disapprove

Rationale:  Function will be maintained even under realignment.

Recommendation:
1.37  Create a new organization unit called Health Administration Service (HAS) comprised of:
(1) the former VACO Medical Administration Service,  (2) the Health Eligibility Center to include the current Income Verification Matching (IVM) Center, Atlanta, GA, and the  (3) The Health Administration Center, Denver, CO.  (CHAMPVA)

Action Required:  1.37.1	 Establish the sub-organizational unit, Health Administration Service (HAS)
	
Action Office :  Chief Admini-strative Officer (CAO)	

Target Date :  On or about Oct. 1, 1995

Comments:  None


Recommendation:
1.38  Task the CAO with convening a task force to review current staffing and function in each of the sub-organizational elements of the HAS for retention,  shift to Service Support Center or deletion.
	
Action Required:  			
1.38.1	The CAO will convene a task force to conduct a thorough analysis of current staffing and functions of MAS, Health Eligibility Center, and Health Administration Center.  The report, for submission to the DUSH, should consider reduction of supervisory levels, consolidation of functions where appropriate, elimination of functions no longer necessary and consideration of the role of the Support Service Center.  Task Force membership should include "unbiased third parties". 
	
Action Office   CAO	

Target Date   Jan. 12, 1996
			

1.38.2  Implement recommendations of the Task Force that have been approved by the DUSH to streamline the new HAS organization.
	
Action Office CAO	

Target Date   Dec. 31, 1996
			
Comments	
1.38  One writer notes that the creation of the Health Administration Service and its proposed consolidation implies a reduction in HQ of the present Medical Administration Service HQ staff.  The writer asks what are the proposed staff savings involved with this consolidation?		

Rationale:  Commentary is noted.  Savings and reductions will be identified as part of the analysis referenced in this recommendation to be initiated by the CAO.	
	


Recommendation:
1.39   Centralize fee-basis claims processing to the CHAMPVA Center in Denver, CO

Action Required		
1.39.1 	The CAO will convene a task force to include CHAMPVA Officials and staff from field facilities to determine the number of FTEE needed in Denver to accomplish centralized claims processing and identify the number of FTEE currently performing this function across the system.
	
Action Office   CAO	

Target Date   Oct. 1, 1995
			

1.39.2	The Task Force will complete their report for submission to the DUSH.  The report will include staffing and FTEE available for redeployment.
	
Action Office   CAO	

Target Date   Dec. 31, 1995			
	
Comments:  1.39  The Deputy Asst Secretary for Financial Mgt. questioned the feasibility or need to centralize Fee Basis payments with CHAMPVA since a large portion of these payment will, as of January 1, 1996, be made out of PAID.  This arises from an agreement VA made with the IRS in order to comply with federal tax withholding and reporting requirements.  Further, Financial Management believes that the VAMCs should retain accountability for Fee Basis claims since they are responsible for appointments, assigning work, scheduling appointments, and ensuring proper payment.  It is recommended that further review be accomplished before settling on this approach to centralize. 	  

Disapprove

Rationale:  Noted, and can be considered as part of the recommended critical analysis.	
	
Comments:  1.39  One VAMC Director concurs with centralized processing of fee basis payments, but recommends that the management of fee basis funds remain at the VISN level to create incentives for cost efficiency.  He emphasizes that the avoidance of interest payments should be a priority for the new Health Administration Center in Denver. 	 

Approve

Rationale:  Commentary consistent with report recommendation.	
	
Comments:  1.39  One VAMC Director recommends that steps be taken to assure that a centralized fee basis claim processing center can process claims in a timely manner. 	 

Approve

Rationale:  Commentary consistent with report recommendation.		

Comments:  1.39  One commentary notes that this recommendation to have fee basis payments performed by CHAMPVA is similar to the modified CALM proposal that was tried and failed.  The writer emphasizes that the decision was not made by contacting staff in the field or ISC representatives.  The writer expresses concern that at face value this seems to cost VHA more, as modifications will need to be made in the Fee Basis DHCP package in order to pass information to CHAMPVA and to retrieve information to update the DHCP database.  The proposal may also appear to be cheaper to decentralize all of fee, make any one-time improvements in the payment process at the field level, and eliminate positions.  The writer strongly recommends that an impartial cost-benefit analysis be performed. 	 

Approve

Rationale:  Commentary consistent with report recommendation.		

Comments:  1.39  One comment emphasizes that with the move to primary care and increased access points, reliance on fee basis programs should be reduced.  The writer challenges the recommendation noting, "If fee care is centralized to anything greater than the VISN level, then a facility director would be foolish to do anything but authorize fee care for veterans who require the most cost intensive care as it would not affect that VAMCs dollars and would be paid from a centralized fund control point.  With decentralization, there comes accountability including fiscal accountability.  Each VAMC and VISN director should determine the most cost effective avenue of ensuring care.  The clause, geographically inaccessible, that is the prime consideration for fee care will be significantly impacted by future VHA changes."  The writer recommends not to centralize the fee basis program. 	   D			

Other
	
One writer emphasizes a correction to the information stated in the 'Assumptions' for this section.  The writer notes that 'Hospital-based Home Care' is misnamed Home-based Hospital Care in the workgroup document.  Also, the writer emphasizes that Hospital-based Home Care is not a fee-basis program and should not be referenced as such.  The commentary clarifies that 'Hospital-based Home Care is designated as a Special Program under PCS and provides primary care through an interdisciplinary team of VA staff.' 		

Commentary unclear.	
	
	



Recommendation:
1.40  Transfer needed FTEE from the VAMCs to the CHAMPVA Center and return remainder of the FTEE to the VISN directors for redeployment.
	
Action Required	:  1.40.1 Redeploy staff in order to accomplish centralized payment.
	
Action Office :  CAO	

Target Date :  Jun. 1, 1996
			
Comments: None

					



Recommendation:
1.41  Consolidate all construction related programs in the Office of Construction Management.
  
1.41.1   Transfer the construction related functions and staff  located in the Office of the Chief Financial Officer to the Office of Construction Management.  These include 25 FTEE assigned to the  Infrastructure Policy and  
Development Office, and 10 FTEE assigned to  Construction Budget Formulation.
	
Action Required	:  1.41.1.a  Complete the transfer of construction related functions and staff.	

Action Office :  Chief Construction Management Officer (CCMO)
	
Target Date :  Oct. 1, 1995

1.41.1.b.   The DUSH will task the CCMO to analyze these functions to include (a) those that should remain in HQ and (b) those which could be performed at the Support Service level and (c) those that should be eliminated.  	

Action Office :  Chief Construction Management Officer (CCMO)
	
Target Date :  Oct. 1, 1995     			

1.41.1.c  The completed task force report with recommendations, including FTEE recommendations will be submitted to the DUSH.
	
Action Office :  Chief Construction Management Officer (CCMO)
	
Target Date:   Jan. 12, 1996
			
Comments:  	
1.41  One VAMC Director emphasizes that the current downsizing of construction budgets should be reflected in a concomitant reduction in size of the Construction Management Office.  	  

Approve

Rationale:  To be evaluated for consideration following reorganization.	
	
Copmments:  1.41  One commentary notes that it is critical that all analyses of the Construction Management Office (CMO) and its components recognize the importance of their role in the State Home Construction Grant Progrm.  The writer emphasizes that their  functions in relation to this program must remain in HQ in order to maintain the efficient operation of this Federal/State sharing program. 	   

Approve

Rationale: Refer for consideration following reorganization.	
	
Comments:  1.41  One commentary notes that the moving of the Infrastructure Policy and Development Office, Construction Budget Formulation, and Delegated Construction programs under CM has been tried several times over the past twenty years.  It has never worked in the past.  The writer expresses concern that to go back to a system that did not work appears to be less than progressive.  He recommends a better approach would be for the VISNs and the VISN Service Centers to develop a data driven process for providing these function in conjunction with the CNO.  He emphasizes that this approach would be more consistent with the stated goals of this reorganization.	   

Approve

Rationale:  It is believed that the Chief Construction Management Officer (CCMO) will seriously and constructively address these functions following reorganization.		
	



Recommendation:
1.41    Consolidate all construction related programs in the Office of Construction Management.
1.41.2  Transfer the major portion of the Engineering Management and Field Support Office. (EMFSO)
	
Action Required		
1.41.2.a 	  Transfer  the minor/minor miscellaneous construction program and the delegated construction program to the Office of Construction Management - plus 14 FTEE.    See also recommendations 1.32 and 1.33.
	
Action Office :  CCMO
	
Target Date :  Oct. 1, 1995 
  
1.41.2.b  Realign the Engineering Service Center in St. Louis to the Office of Construction Management - plus 14 FTEE   See also Recommendation 1.35.	

Action Office :  CCMO	

Target Date :  Oct. 1, 1995			
	
Comments:  1.41.2, 1.41.2.b  The Chief Engineers Advisory Board (CEAB) expressed concerns regarding the movement of EMFSO to the CMO citing past alignment of the Office of Facilities under Construction Management with very limited success.   The CEAB further requests representation on any group that will make final disposition of current functions of EMFSO.  	   

Disapprove

Rationale:   The functions of EMFSO as a whole will move to Construction Management.   The Vision for Change  abolishes Operations of which EMFSO was formally located.	
	
Proposed Revision
1.41.2 Revised	Consolidate all construction related programs in the Office of Construction Management.
 1.42.2.  Transfer the entire portion Engineering Management and Field Support Office (EMFSO).		
	



Recommendation:
1.42  Transfer construction management budget execution functions from the Office of Construction Management to the Chief Financial Officer.
	
Action Required		
1.42.1	Transfer construction management budget execution function from the Office of Construction Management to the CFO.
	
Action Office   CCMO and CFO	

Target Date Oct. 1, 1995
			

1.42.2	Determine associated FTEE to be transferred with this function by conducting a joint review by the CFO and CCMO.
	
Action Office CCMO and CFO
	
Target Date   Oct. 1, 1995
			
Comments:  1.42  The AsCMD for Construction Management (CM) supports transferring a portion of the budget execution function to the CFO.  The budget execution staff also serves NCS and VBA customers.  The removal of this entire function from CM would result in reduced service to CM's many customers.  It is recommended that the AsCMD negotiate this issue with the CFO and provide a written recommendation by January 12, 1996. 
	  
Approve

Rationale:  Consistent with the action recommended in 1.42.2.	
	
	


Recommendation:
1.43Consolidate information resource management functions through transferring a selected portion of the information management staff in the Office of Construction Management to the Office of the Chief Information Officer.
	
Action Required			
1.43.1	Determine the final number of Construction Management IRM personnel to be transferred through a joint review completed by the CIO and CCMO.	

Action Office   CIO and CCMO
	
Target Date   Oct. 1, 1995
			
1.43.2  	Transfer appropriate FTEE determined as a result of the review.
	
Action Office   CCMO
	
Target Date   NTE Dec. 1, 1995
	
Comments:		
1.43.1	The AsCMD for Construction Management (CM) comments that CM recognizes the need stated by the workgroup for effective information systems support for HQ staff, some of whom may be presently under-served.  The critical need for support is met through the Information Management Office of CM which supports on-line access to a variety of CM, HQ, field, and non VHA  staff such as NCS and Congressional Affairs.  CM emphasizes that they are engaged in active discussions with the Director of MIRMO and his staff to determine how to expand effective desktop support to a greater number of HQ staff.  
	   
Approve

Rationale:  This issue is addressed within recommendation, specifics can be worked out between the Chief Information Officer and the AsCMD for Construction Management (i.e., proposed title change to Chief Construction Management Officer).		

		



Recommendation:
1.44  Create a new headquarters administration function, composed of a portion of the current Office of Construction Management administrative support, for overall administrative support of the internal operation of VHA headquarters to assure the basics of a functional office environment.
	
Action Required	:		
1.44.1  The CAO and CCMO will recommend members of a multi-organization/disciplinary team to evaluate VHA needs for a consolidated office support function as part of the Management and Administration Support Office (MASO).
	
Action Office   CAO and CCMO	

Target Date   Oct. 1, 1995
			

1.44.2	The final report and recommendations will be prepared for the DUSH, and should consider the transfer of three staff from the Administrative Support Office located in the Office of the USH.
	
Action Office   CAO and CCMO
	
Target Date   Dec.  1, 1995
			
Comments:  None
		




Recommendation:
1.45  Transfer several functions from the Office of the CFO to other HQ programs.
	
Action Required				
1.45.1 	Transfer strategic planning [including 9 FTEE], and policy analysis functions [including 4 FTEE] to the Office of Policy, Planning and Performance.	

Action Office   Office of PPP
	
Target Date   Oct. 1, 1995
			
1.45.2 	Transfer the OIG/GAO liaison function [including 5 FTEE] to the Office of Policy, Planning and Performance.
	
Action Office   Office of PPP
	
Target Date   Oct. 1, 1995
			
1.45.3	Transfer the construction related functions located in the present Infrastructure Policy and Development Office [including 25 FTEE} to the Office of Construction Management.
	
Action Office   CCMO	

Target Date   Oct. 1, 1995			

1.45.4 Transfer the Construction Budget Formulation function [including 10 FTEE] to the Office of Construction Management.
	
Action Office   CCMO
	
Target Date   Oct. 1, 1995
			
1.45.5	Transfer the Decision Support System  (DSS) to the Chief Information Officer. - [70 FTEE includes Kansas City and multiple locations]   (Reference also recommendation 1.51).
	
Action Office   CIO
	
Target Date   Oct. 1, 1995			
	
Comments	
1.45.2  	The Deputy Asst Secretary for Financial Mgt does not support the realignment of this function from the CFO organization, emphasizing the focus on performance measurement.  The varied audit related activities coordinated and/or conducted by the CFO are cited in support of the CFO as the organization with the best knowledge to respond to IG and GAO audits.	   

Disapprove

Rationale:  The OIG/GAO liaison functions referenced include a broader scope than financial audits.  More important to have this function aligned with performance monitoring and the Medical Inspector, as scope of issues are both clinical and administrative to reflect our healthcare system.	
	
Comments:  1.45.2  The Assistant Secretary for Management expresses concern involving the realignment of responsibilities from the CFO regarding the OIG/GAO function.  He remains convinced that the VHA CFO's office possesses the expertise and inherent background to perform these decision functions. 	   

Disapprove

Rationale:  The OIG/GAO liaison functions referenced include a broader scope than financial audits.  More important to have this function aligned with performance monitoring and the Medical Inspector, as scope of issues are both clinical and administrative to reflect our healthcare system.	
	
Comments:  1.45.2  The Director, National Media Development Center comments that one of the stated objectives in this reorganization is the need to eliminate the fragmented approach to VHA education.  He questions that if this is true, it appears inconsistent to move any educational resources or staff to offices other than the new Education office.  This comment assumes that this action includes moving the DSS Education Support Office located in Cleveland to the CIO.  This educational activity is currently dedicated to staff education and training related to DSS; however, the need for this training may well change or be expanded to other automated performance systems.  Therefore, he closes that it seems consistent that this function should become part of employee education and not the CIO. 
	   
Approve

Rationale:  It is appropriate that the DSS Education Support referenced be retained with other employee education resources aligned under the Office of the Employee Education Officer.   The action is revised to clarify the alignment of this function.		

Comments:  1.45.5  The Assistant Secretary for Management notes that locating the DSS function under the CIO is reasonable.  However, he emphasizes that the VHA CFO should retain primary authority over maintaining the system's cost accounting standards. 	   

Approve

Rationale:  Recommendation is consistent with report.	
	
Proposed Revision			
1.45.5 Revised	Transfer the Decision Support System  (DSS) to the Chief Information Officer. - [70 FTEE includes Kansas City and multiple locations].  This excludes staff employees assigned to the DSS Education Support Office located in Cleveland aligned under the Director, National Media Development.
	
Action Office   CIO
	
Target Date   Oct. 1, 1995	
		



Recommendation:
1.46  Transfer to the Office of the CFO the construction management budget execution from the Office on Construction Management,  [exact number to be determined later].

Action Required
1.46.1  Transfer construction mangement budget execution and determine associated FTEE to be transferred by a joint review by the CFO and CCMO.	
	
Target Date   Oct. 1, 1995
			
						
Comments:  None
	

				
		


Recommendation:
1.47Dependent upon adequate justification, expand the current CFO functions to provide the following  functions:  enhance evaluation service, establish business planning function, establish financial audits, enhance financial policy activity to include the revolving fund policy function, and enhance the current rate development and price staff.    (The CFO has requested additional FTEE for each of the above functions.)
	
Action Required			
1.47.1	Create the Office of Financial Evaluation.
	
Action Office   CFO	

Target Date   On or about Oct. 1, 1995			

1.47.2	The CFO will thoroughly analyze staffing required for the sections and functions described for the Office of Financial Evaluation.  A report and recommendations to include sub-elements and functions of Evaluation Service and Post Occupancy Evaluations should be submitted to the DUSH.	

Action Office   CFO	

Target Date   Dec. 1, 1995
			

1.47.3  The CFO will review/study the establishment of a 'financial audit capability' to include (a) out placement of these staff at field locations and (b) the need to continue the financial integrity audits out of Austin, TX. A report and recommendations will be provided to the DUSH.	

Action Office   CFO
	
Target Date   Dec. 1, 1995
			
1.47.4 	The CFO will submit a proposal for the desired additional and enhanced funtions, including function description, justification and staffing, to the DUSH.	

Action Office   CFO
	
Target Date   Nov. 1, 1995
			
1.47. 5 	The CFO, in conjunction with the Chief of PPP, will perform a review for submission to the DUSH to determine the future alignment of the following organizational elements currently assigned to the CFO: (a) Management Science Group at Bedford, includes 12 FTEE; (b) Planning System Support Group at Gainesville, includes 6 FTEE; (c) Planning & Evaluation Front Office, includes 4 FTEE; (d) Statistical Analysis Service, includes 4 FTEE; and (e) the Performance Measurement Service, includes 3 FTEE.
	
Action Office   Office of PPP
	
Target Date   Recommen-dations due by Dec. 1, 1995			

Comments:  1.47.3  The Deputy Asst. Secretary for Financial Mgt. believes that this discussion of the Austin Financial Quality Assurance Service staff exceeds the purpose of the VHA restructuring and recommends that this action be deleted.  It is critical that this independent review function remain with the Department's CFO to ensure that internal controls are not sacrificed as VA undergoes change.  The Department CFO will continue to perform these reviews to provide assurances that policy and systems from a VA perspective are being followed. 	
 
Approve

Rationale:  Concur.  Action 1.47.3 is deleted from report.	
	
Comments:  1.47.3  The Assistant Secretary for Management questions the need of the workgroup to consider any action relative to financial integrity auditing out of Austin., Texas.  He emphasizes that maintaining the independence of this audit review function is critical to his oversight role as the VA CFO/CIRO, and recommends that this action be removed. 	   

Approve

Rationale:  Concur.  Action 1.47.3 is deleted from report.	
	
Proposed Revision	
1.47.3  Delete	
Delete Action:  The CFO will review/study the establishment of a 'financial audit capability' to include (a) out placement of these staff at field locations and (b) the need to continue the financial integrity audits out of Austin, TX. A report and recommendations will be provided to the DUSH.		
	
		


Recommendation:
1.48  Develop a plan for IRM acquisition oversight and independent review; establish a management process for integrating strategic planning efforts in information management and technology investments; establish information technology performance measurement; establish a formal concept approval and acquisition process; and establish an organizational structure to support a formal, life cycle oriented, review process of IRM activities.
	
Action Required				
1.48.1	Classify and recruit for the CIO position.	

Action Office   Office of USH

Target Date   Oct. 1, 1995			

1.48.2	The CIO will  develop a proposed organizational chart reflecting additional FTEE requirements and justification for same.  The proposal for additional FTEE will be submitted to the DUSH.	

Action Office   CIO	

Target Date   Dec. 1, 1995
			
1.48.3	The CIO and appropriate personnel will develop a plan for IRM acquisition oversight, independent review, and identification of processes to address the other components of the review of IRM activities noted above.  The report with recommendations will be made to the DUSH.	

Action Office   CIO
	
Target Date   Dec. 1, 1995
			
Comments:  1.48.3  One VAMC Director notes that no mention is made in the report of ensuring that enhancements are made to information systems to keep them consistent with new programs.  An example is cited in the Prime Vendor programs that require streamlined IFCAP processing menus; yet, over two years after intial implementation, no effort has been made to modify IFCAP.  	   

Approve

Rationale:  Refer to CIO for consideration of action following reorganization.	
	
Comments:  1.48  The Western Region Information Management Group recommends adding the establishment of a database administration (DBA) function within the Office of the CIO.  This would be a database administrator not only for traditional DHCP packages, but for all other VHA databases.  Coordination is needed within VHA and between VHA, VBA, and NCS.  This DBA could also function as liaison with outside agencies in data linkage and data sharing projects. 	   

Approve

Rationale:  Refer to CIO for consideration of action following reorganization.	
	
1.48  Other  One writer emphasizes that the HQ Restructuring and Information Systems Work Group Reports need to both address the exact nature of the role of the CIO.  The writer emphasizes that a final agreement on the CIO function is critical to a number of recommendtions that affect VHA and the proposed CIO organization.  In a lengthy commentary this writer also adds that what is at issue is the nature of the role of the CIO, and points out that the CIO function should not adversely impact or directly interere with program or field activities or operations.  The writer adds that the CIO should be both a policy and support function, but not a function to which all program information components need to organizationally report.
  		
Noted.  The development of functions required for the CIO organization is generalized in describing this office with this report.  Specifics are appropriate for determination between the USH and the individual appointed, and will be further defined as the new  organization evolves and VHA needs are identified.  		
	
			
	
		


Recommendation:
1.49  Determine which information resource management functions of the Office of Construction should be transferred to the CIO.
	
Action Required	:  1.49.1	Transfer Construction Management IRM Personnel to the CIO.
	
Action Office   CCMO	

Target Date   Oct. 1, 1995
			
Comments:  1.49  One writer emphasized concern that by assuming the CM IRM functions and staff, clear responsibility and functional statements need to be provided.  The implication is that the CIO will assume responsibility for VHA HQ information systems infra structure support.  The writer says that the argument used to support the transfer of CM IRM staff to the CIO is that the CIO office 'provide direction, leadership and management over information management activities at the Administration level.'  The writer emphasizes that the basic justification underlying this transfer needs to be reexamined.  The writer adds that CM has developed an IRM support function because one was not provided by MIRMO or VHA Administration.  The activity performed by the CM IRM improves the work environment and efficiency of the CM organization.  It does not compete with or affect IRM policy or process decisions or functions managed by MIRMO or the CIO.  The writer notes that transfer of this function sends a strong negative message to all organizations that is certain to limit creative solutions to organizational issues. 		

Commentary is noted.  However, the CCMO will determine with input from the new CIO which functions and/or staff are appropriate for realignment to the CIO.  	
	

Recommendation:
 1.50  Integrate the present Library and Satellite TV into the CIO organization structure.  3.0 FTEE in HQ and 5.0 FTEE (Washington, Cleveland, Salt Lake, and St. Louis) in the field.

Action Required			
1.50.1 	Integrate the Library, and Satellite TV into the CIO organization. 
	
Action Office   CCMO	

Target Date   Dec. 1, 1995
			
1.50.2	The CIO will develop a plan and time frame for the out placement of existing staff to the field or VISN Service Support Centers, as necessary.  This plan should include the development of education and cross training programs to produce a positive transition.
	
Action Office   CCMO
	
Target Date   Dec. 1, 1995
		
			
Comments:  1.50  One writer questioned the accuracy of the FTE count associated with this function.  The writer asks if it is the intention to include both the National Library Program Office and VHA's Library and Visual Information staff within the CIO. The writer notes that an hierarchial relationship does not exist between these two functions.  However, it is logical to place both activities under the CIO, and if this is the intent further clarification of the number is needed. The writer points out that in addition to the sites noted in the recommendation, FTE are physically located also at Birmingham and Durham.  Also the writer notes that conceivably some of these FTE could be placed in the Employee Education Office since a large portion of their work is associated also with education and RMEC support.  		

Noted.  The HQ workgroup noted many inconsistencies in the organization alignment and staff numbers associated with out placed units that support HQ activities.  As the introductory comments indicate, further review of HQ out placed units, their functions, and alignment is the subject of further review by the DUSH.	
	


Recommendation:
1.51   Transfer the DSS from the CFO to the CIO. - 70 FTEE which includes HQ and field units.
	
Action Required			
1.51.1	Realign the DSS function from the CFO to the CIO.  (Reference also action 1.45.5).
	
 Action Office CIO
	
Target Date   Oct. 1, 1995 
			
Comments:  1.51  The Deputy Asst Secretary for Financial Mgt.  does not disagree with the realignment of the DSS function to the CIO.  However, it is emphasized that the CFO responsibility for the cost accounting component in DSS should be clarified.  It is not addressed in the report that the CFO will have the lead responsibility for ensuring implementation of governmentwide and department cost standards associated with DSS. 	  

A pprove

Rationale:  Matrixed functions of DSS between CIO and CFO will be addressed in the performance contract of each official.	
	

				

Recommendation:
1.52  The Management and Administration Support Office (MASO), in conjunction with Human Resources and/or other appropriate HQ program offices, will initiate prompt action to develop and/or revise a variety of personnel related issues and/or activities necessary to implement the new HQ organization.  These issues/activities include, but are not limited to the following;  organizational and staffing charts, functional statements, mail symbols, telephone numbers, space allocations, time and leave unit designations, title changes and mass change actions. 

Action Required			
1.52.1 	Initiate appropriate documents to obtain approval of the Secretary as appropriate.
	
Action Office   MASO	

Target Date   To be Determined			

1.52.2  Initiate revisions to Organization and Staffing Tables immediately upon approval.
	
Action Office   MASO	

Target Date   To be Determined			

1.52.3   Initiate requests to Program Offices/Strategic Health Care Group Leaders for revised functional statements and positions descriptions.	

Action Office   MASO	

Target Date   To be Determined			

1.52.4 	Identify needed changes in space allocation, cost centers, mail symbols, telephone numbers, and PAID language.
	
Action Office   MASO	

Target Date   Sept. 15, 1995			

1.52.5  	Develop priority Personnel Placement Program, in conjunction with Office of Human Resources Management.
	
Action Office   MASO	

Target Date   Sept. 15, 1995			

1.52.6 	Initiate mass change actions.
	
Action Office   MASO
	
Target Date   Sept. 29, 1995			

1.52.7  Maintain dialogue with Labor Organizations. 
	
Action Office   MASO	

Target Date   Ongoing			

Comments  1.52  Individuals (2) expressed concern that no recommendations were made to assure effective communications with HQ employees.  A clarification of the plans that MASO have made to enhance communication and control the rumor mill was requested. 
	  
Approve	

Rationale:  This will be referred to MASO for incorporation into new functions.	
	
Comments   1.52.4  The Deputy Asst Secretary for Financial Mgt recommends that changing cost center codes only be accomplished at the beginning of the fiscal year due to core system impacts (FMS, PAID,etc.) and emphasizes the need to coordinate changes with IRM/OFM.	 

Approve
	 
Rationale:  Refer to MASO for consideration/action.	
	
Comments   1.52.5  The Assistant Secretary for Human Resources and Administration notes that clarification with VHA regarding the personnel placement program is needed.  If the intent is to develop a HQ special placement program, that would in ordinary circumstances be appropriate; however, given prospective budget levels, many other HQ elements may also need to be downsizing.  If the intent is to focus on outplacment within VHA (HQ and field) or on other alternatives, this would represent a different situation. 
	  
Approve

Rationale:   Refer to MASO for consideration/action.