=

Department of 

Veterans Affairs 

Independent Review

of VA’s Fiscal Year 2010 

Performance Summary 

Report to the 

Office of National

Drug Control Policy 

March 17, 2011

11-00314-123

VA Office of Inspector General

OFFICE OF AUDITS AND EVALUATIONS
To Report Suspected Wrongdoing in VA Programs and Operations:

Telephone: 1-800-488-8244

E-Mail: vaoighotline@va.gov

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) 
i

Department of

Veterans Affairs

Memorandum

Date: March 9, 2011 

From: Assistant Inspector General for Audits and Evaluations (52) 

Subj: Final Report – Independent Review of VA’s Fiscal Year 2010 Performance Summary 

Report to the Office of National Drug Control Policy 

To: Acting Deputy Chief Patient Care Services, Veterans Health Administration (116) 

Chief Research and Development Officer, Veterans Health Administration (12)

1. The Office of Inspector General is required to review the Department of Veterans 

Affairs’ (VA) Fiscal Year (FY) 2010 Performance Summary Report to the Director, 

Office of National Drug Control Policy (ONDCP), pursuant to ONDCP Circular: Drug 

Control Accounting (Circular), dated May 1, 2007, and as authorized by 21 U.S.C. § 

1703(d)(7). T he Performance Summary Report is the responsibility of VA’s 

management and is included in this report as Attachment A (Patient Care) and 

Attachment B (Research and Development). The Circular is included as Attachment C.

2. We reviewed whether VA has a system to capture performance information accurately 

and if that system was properly applied to generate the performance data reported in the 

Performance Summary Report. We reviewed whether VA offered a reasonable 

explanation for failing to meet a pe rformance target and for any recommendations 

concerning plans and schedules for meeting future targets or for revising or eliminating 

performance targets. We also reviewed whether the methodology described in the 

Performance Summary Report and used to establish performance targets for the current 

year is reasonable given past performance and available resources. Finally, we 

reviewed whether VA has established at least one acceptable performance measure for 

each Drug Control Decision Unit, as defined by the Circular, for which a significant 

amount of obligations were incurred. 

3. Our review was conducted in accordance with attestation standards established by the 

American Institute of Certified Public Accountants, and the applicable standards 

contained in Government Auditing Standards, issued by the Comptroller General of the 

United States. An attestation review is substantially less in scope than an examination. 

The objective of an examination is the expression of an opinion on the matters 

described in paragraph two. Accordingly, we do not express such an opinion. 

4. Based upon our review and the criteria of the Circular: 

 Nothing came to our attention that caused us to believe that VA does not have a 

system to capture performance information accurately and the system was not 

properly applied to generate the performance data reported in the Performance 

Summary Report in all material respects;
ii

 Nothing came to our attention that caused us to believe that VA did not meet its 

FY 2010 target for the continuity of care performance measure (Patient Care) and 

the substance abuse disorder on-going studies performance measure (Research and 

Development), in all material respects. As a result, VA is not required to offer an 

explanation for failing to meet a performance target, for recommendations 

concerning plans and schedules for meeting future targets, or for revising or 

eliminating performance targets;

 Nothing came to our attention that caused us to believe that the methodology 

described in the Performance Summary Report establishing performance targets 

for the current year is not reasonable given past performance and available 

resources, in all material respects; and

 Nothing came to our attention that caused us to believe that VA did not establish at 

least one acceptable performance measure for each Drug Control Decision Unit, as 

defined by the Circular, for which a significant amount of obligations were 

incurred in the previous fiscal year, in all material respects. 

5. We provided you our draft report for review. You concurred with our report without 

further comments. 

6. This report is intended solely for the information and use of the U.S. Congress, the 

ONDCP, and VA management. T his report is not intended to be and should not be 

used by anyone other than these specified parties. 

(original signed by:)

BELINDA J. FINN

Attachments
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A 

1

January 4, 2011

Belinda J. Finn 

Assistant Inspector General for Auditing (52)

Office of Inspector General

Department of Veterans Affairs

Dear Ms. Finn:

As required by Section 7 of the Office of National Drug Control Policy (ONDCP) Circular, Drug 

Control Accounting, dated May 1, 2007, enclosed please find the Performance Summary Report for the 

Veterans Health Administration for your authentication in accordance with the guidelines in Section 8 of the 

Circular.

We certify that the Veterans Health Administration has established a performance measure for its drug 

activities; that the methodology to generate this measure is appropriate and accurate; and that the target level for 

the performance measure is reasonable. 

The Veterans Health Administration achieved its target performance goal for fiscal year (FY) 2010.

Sincerely,

(original signed by:)

Antonette Zeiss, PhD

Acting Deputy Chief Patient Care Services

Officer of Mental Health

Enclosure
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A 

VA Office of Inspector General 2

Department of

Veterans Affairs Memorandum

Date: December 28, 2010

From: Chief Quality and Performance Officer

Subj: Management Representation Letter for the Independent Review of the VA’s FY 2010 Performance 

Summary Report to the Office of National Drug Control Policy (Project Number 2011-00314-R1-

0011) To: Assistant Inspector General for Audits and Evaluations (52)

We are providing this letter in connection with your attestation review of our Performance Summary 

Report to the Director, Office of National Drug Control Policy (ONDCP). We confirm, to the best of 

our knowledge and belief, that the following representations made to you during your attestation 

review are accurate and pertain to the fiscal year ended September 30, 2010.

1. We confirm that we are responsible for and have made available to you the following:

a. The Performance Summary Report for FY 2010 required by the Circular;

b. All supporting records and related information and data relevant to the Continuity of Care 

performance measure within the FY 2010 Performance Summary Report; and

c. Communications, if any, from the ONDCP and other oversight bodies concerning the FY 2010 

Performance Summary Report and information therein.

2. We confirm that the FY 2010 Performance Summary Report was prepared in accordance with the 

requirements and criteria of the Circular.

3. We understand your review was conducted in accordance with the attestation standards established by 

the American Institute of Certified Public Accountants, and the applicable standards contained in 

Government Auditing Standards, issued by the Comptroller General of the United States. An 

attestation review is substantially less in scope than an examination and accordingly, you will not 

express an opinion on the Performance Summary Report and related disclosures.

4. No events have occurred subsequent to September 30, 2010, that would have an effect on the 

Performance Summary Report and the information therein.

(original signed by:)

Joseph Francis, MD, MPH

Attachment
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A 

VA Office of Inspector General 3 

Department of Veterans Affairs 

Veterans Health Administration 

FY 2010 Performance Summary Report 

I. PERFORMANCE INFORMATION 

Decision Unit 1: 

Measure 1: 

Veterans Health Administration 

Continuity of Care 

This measure was established to promote better substance use disorder (SUD) treatment 

outcomes. It applies to patients entering specialty treatment for SUD in inpatient, residential, 

domiciliary or outpatient programs, but not opioid substitution, to determine if they are staying in 

treatment for at least 90 days. Research has shown that good addiction treatment outcomes are 

contingent on adequate lengths of treatment. Many patients drop out during the initial 90 days of 

treatment with limited clinical benefit and high rates of relapse. While two contacts per month 

for at least three months would rarely be sufficient, most patients with chronic conditions require 

ongoing treatment for at least this duration to establish early remission. Note: SUD includes 

patients with an alcohol or drug use disorder diagnosis or both. 

Indicator: Percent of patients beginning a new episode of treatment for SUD who maintain 

continuous treatment involvement for at least 90 days after qualifying date 

Numerator: Veterans beginning a new episode of treatment for SUD who maintain continuous 

treatment involvement for at least 90 days as demonstrated by at least 2 days with visits every 30 

days for a total of 90 days in any of the outpatient specialty SUD clinics. 

Denominator: Veterans beginning a new episode of specialty treatment for SUD 

(b) In FY 2010, 52% of VA patients in a specialized SUD program successfully met the measure, 

exceeding the target of 47%. 

(c) Performance results are updated monthly on a VA intranet site and discussed on semimonthly 

national conference calls. In addition to establishing standards and providing feedback, pay 

incentives of leaders at the network, facility, service, and program level are directly linked to 

these quality metrics. Expansion funding over the past several years has been used to improve 

the continuum of care in order to promote retention. This includes efforts to arrange accessible 

transitional housing to facilitate program attendance and establishing telemental health services 

capability at additional locations. Consultation is offered through national resources including 

the Substance Use Disorder Quality Enhancement Research Initiative and the Centers of 

Excellence in Substance Abuse Treatment and Education. Informatics tools are shared within 

and across VISNs to promote active patient tracking and outreach. 

FY 2006 

Actual 

FY 2007 

Actual 

FY 2008 

Actual 

FY 2009 

Actual 

FY 2010 

Target 

FY 2010 

Actual 

FY 2011 

Target 

37% 44% 48% 52% 47% 52% 47% 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A 

VA Office of Inspector General 4 

(d) Performance Measures are maintained by the VHA Office of Quality and Performance. In 

the case of the SUD measure, workload data generated at the facility is transmitted to the VHA 

Austin Information Technology Center. The extraction methodology uses the appropriate DSS 

identifier codes (stop codes) to select the patients who meet the criteria for inclusion in the 

measure. The patient data is then extracted from the Austin PTF files and is maintained by the 

Office of Quality and Performance. A copy of the FY 2010 Office of Quality and Performance, 

Substance Use Disorder, Continuity of Care Technical Manual Chapter is attached. 

II. MANAGEMENT’S ASSERTIONS 

(1) Performance reporting systems appropriate and applied. Performance Measures are 

maintained by the VHA Office of Quality and Performance. In the case of the SUD measure, 

workload data generated at the facility is transmitted to the VHA Austin Data Center. The 

extraction methodology uses the appropriate DSS identifier codes (stop codes) to select the 

patients who meet the criteria for inclusion in the measure. The patient data is then extracted 

from the Austin PTF files and is maintained by the Office of Quality and Performance. The 

system was properly applied to generate the performance data. 

(2) Explanations for not meeting performance targets are reasonable. In FY 2010 the target 

of 47% was exceeded with an actual rate of 52%. 

(3) Methodology to establish performance targets is reasonable and applied. The target 

measures are set by the VHA Office of Quality and Performance in conjunction with the Office 

of Patient Care Services. The target set for FY 2011 is 47% and the reporting will continue as 

already established.

(4) Adequate performance measures exist for all significant drug control activities. VHA is 

measuring the identification and treatment of those having a SUD issue. 

Performance

This section on FY 2010 performance is based on agency Government Performance and Results 

Act (GPRA) documents, an OMB assessment, and other agency information. VHA reports 

performance for two separate drug-related initiatives: (1) health care and (2) research and 

development. The table below includes target and achievement levels on performance measures 

for the most recent year. VHA’s health care performance measure for ONDCP reporting 

purposes is “continuity of care” (i.e. the percent of patients who have engaged in SUD treatment 

as demonstrated by being seen for at least three visits in a month and who persevere in SUD 

treatment by being seen for at least two treatment sessions per each of the following three 

months. 

VHA has in place a national system of performance monitoring that uses social, professional, 

and financial incentives to encourage facilities to provide the highest quality health care. This 

system has begun to incorporate performance measures related to substance use disorder 

treatment. 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A 

VA Office of Inspector General 5 

The dollars expended in VHA research help to acquire new knowledge to improve the 

prevention, diagnosis, and treatment of disease. These funds also generate new knowledge to 

improve the effectiveness, efficiency, accessibility, and quality of veterans’ health care. 

VHA Research currently supports a number of projects on drug and alcohol abuse. These 

include “Alcohol, Aging, and Brain Functions,” “Alcohol Antagonists,” “Impact of PTSD on 

Marijuana Use Treatment Outcome,” and “Dysregulation of CNS Stress System in Acute Opioid 

Dependence/Withdrawal.”

Performance Measures for Treatment and Research for FY 2010

Target Actual

» 47% 52%

» 5 21

» 5 46

»

NA 14

Number of research studies related to alcohol abuse

Number of research studies related to both substance use 

disorder and alcohol abuse

Percent of clients receiving appropriate continuity of care

Research and Development

Number of research studies related to substance use disorder
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A

VA Office of Inspector General 6 

Discussion of Current Program

In FY 2010, VHA provided services in a specialty SUD setting to 108,210 patients with a drug 

diagnosis. Of these, 46 percent used cocaine, 26 percent used opioids and 36 percent used 

cannabis. Seventy-five percent had co-existing psychiatric diagnoses. (These categories are not 

mutually exclusive.) 

VA provides two types of 24-hour-a-day care to patients having particularly severe or acute 

substance use disorders. These include care in residential rehabilitation treatment programs for 

substance use disorders and inpatient detoxification in numerous medical and general mental 

health units. 

Most Veterans with substance use disorders are treated in outpatient programs. Outpatient 

detoxification is available for patients who are medically stable and who have a sufficient social 

support system to monitor the patient. Intensive substance use disorder outpatient programs 

provide at least three hours of service per day and patients attend three or more days per week. 

Standard outpatient programs typically treat patients one or two hours per session and patients 

are generally seen once or twice a week. 

VHA is steadily expanding the availability of opioid agonist treatment for opioid-dependent 

Veterans. VA operates methadone maintenance programs at 31 of its 139 facilities. At 23 VA 

facilities it maintains contractual arrangements for providing these services through communitybased licensed opioid agonist treatment programs. Further, 118 VA facilities prescribed 

buprenorphine to VA patients in FY 2010 reflecting the growing availability of office-based 

opioid agonist treatment. In sum in FY 2010 121 of 139 VA facilities (87%) provided opiate 

agonist treatments in-house, through a contracted licensed opioid agonist treatment program or 

via office-based opioid agonist treatment in FY2010. 

VA is also in the process of implementing initiatives to expand access to SUD treatment 

services. This has focused on hiring new substance use disorder specialists to work in a variety 

of VA health care settings. Eighty-six percent of the 406 additional SUD staff assigned to work 

in large community based outpatient clinics, mental health residential rehabilitation programs, 

intensive SUD outpatient programs and PTSD teams have now been hired or have a set date to 

begin work. Sixteen additional SUD specialist positions to support Health Care for Homeless 

Veterans program and 101 to support the VA-HUD initiative to provide housing to homeless 

Veterans were very recently funded and are in early stages of being filled. 

VA is currently conducting a one-year demonstration study at 41 intensive outpatient substance 

use disorder treatment programs to anticipate and resolve issues that would surround systemwide employment of the Brief Addiction Monitor (BAM). The BAM is designed to assist SUD 

specialty care clinicians in monitoring the progress of patients while they are receiving care for a 

substance use disorder, serving as a basis for giving feedback to them to enhance their 

motivation for change, and informing clinical decisions, such as the intensity of care that a 

patient needs. 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A

VA Office of Inspector General 7 

FY 2010 Q4

Volume 2

Clinical Measures

Specification Manual

Office of Quality and Performance (10Q)

June 9, 2010

Note: portions of the technical manual are FOIA protected therefore the Technical 

Manual is not for public distribution. 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A

VA Office of Inspector General 8 

HSI 9i Substance Use Disorder – Continuity of Care

Description: This measure applies to patients entering specialty treatment for substance use 

disorders (inpatient, residential, domiciliary or outpatient, but not opioid substitution), to 

determine if they are staying in treatment for at least 90 days. It involves 100% review of 

administrative databases using clinic stop codes to determine specialty care of substance use 

disorders (SUD). Research has shown that good addiction treatment outcomes are contingent on 

adequate lengths of treatment. There is no predetermined length of addiction treatment that 

assures success, but duration of treatment is the factor most consistently associated with 

successful addiction treatment outcome. Many patients drop out during the initial 90 days of 

treatment with limited clinical benefit and high rates of relapse. While two contacts per month 

for three months would rarely be sufficient, most patients require ongoing treatment for at least

this duration to establish early remission. 

Various patient, provider and program level interventions have been associated with improved 

treatment retention. The initial intensity of treatment should be considered primarily as a means 

to promote treatment retention, e.g., severely dependent patients typically may require multiple 

treatment contacts per week in order to stabilize early remission. However, for many patients 

following initial stabilization, it may be appropriate to provide a lower intensity of addictionfocused treatment extending over a longer duration with superior remission rates for those who 

remain engaged in treatment for 6-12 months. Available evidence supports the effectiveness of 

telephone follow-up for patients after they have stabilized during the initial weeks of outpatient 

treatment. Many individuals continue to benefit from treatment (e.g., methadone maintenance) 

over a period of years. 

Consistent with the VHA/DoD Guideline for Treatment of Substance Use Disorder, this 

performance measure is intended to emphasize the importance of early treatment retention as an 

essential condition of quality care for addiction. Treatment duration beyond 3 months presents 

important opportunities to individualize treatment plans consistent with treatment response over 

time by adjusting the intensity of psychosocial interventions (e.g., frequency of group sessions), 

pharmacotherapy (e.g., dose amount and monitoring frequency), community recovery support

(e.g., promoting Twelve-Step program involvement), and management of co-morbid conditions.

 

 Mnemonic: sa5

 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A

VA Office of Inspector General 9 

 

 

Numerator: Veterans beginning treatment for SUD who maintain continuous treatment 

involvement for at least 90 days as demonstrated by at least 2 days with visits every 30 days for a 

total of 90 days in any of the outpatient specialty SUD clinics

Denominator: Veterans beginning specialty treatment for SUD

Catnum (#)/Cohort: Universe includes all Veterans with an SUD outpatient encounter or 

inpatient discharge from SUD specialty bed section in VHA. 

Age (specify):

Acceptable care setting: Outpatient 

Defining characteristics: 

Table of relevant ICD-9/DSS codes:

Summary of Quarterly changes

 Indicator Statement/Description: Percent of patients beginning a new episode of treatment for 

SUD who maintain continuous treatment involvement for at least 90 days after qualifying date.

 

Eligible Population: 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A

VA Office of Inspector General 10

• Non Veterans are excluded from this measure. They are identified by either a means test 

response of “n”, “no” (zero) which represents a “non-vet”, or by eligibility status 

indicating non Veteran. 

• Patients without an initial enrollment date

• Patients discharged, dead or deceased during the 90-day retention period. To be captured 

for this measure, data must be in AITC or Beneficiary Identification Record Locator 

System (BIRLS).

• Smoking cessation visits are excluded. When stop code 707 is paired with any SUD code, 

the SUD visit is not used. 

• All clinic visits, except those listed here are excluded from measure. Clinic visits to 

outpatient SUD clinic stop 513 SA-IND or 514 SA-Home or 519 SA/PTSD, 523 Opioid 

Substitution, 545 SA Telephone, or 547 intensive-SA TRT GRP, or 548 intensive-SA TRT 

IND or 560 SA GRP are included in this measure. See Table A below for discussion on 

the use of 545 Telephone, 514, SA HOME, 519 SA/PTSD and 523 Opioid Substitution

• Veterans seen in multiple facilities will be attributed to the facility where the last retention 

visit occurred in order to promote coordinated transitions between facilities. 

. 

All other clinic visits, including non SUD clinic visits are not considered in this measure. 

o If the Veteran is not

o If the Veteran is seen for a 1st retention visit in a substance abuse clinic during the 1st 

30-day retention period but is not seen again, the patient fails the measure. The failure 

will be attributed to the facility where the first retention visit occurred. 

 seen in any substance abuse clinic in VHA during the 1st 30 days 

of the retention period, he fails the measure. The failure will be attributed to the 

facility where the ‘qualifying’ event occurred (i.e. where the 3rd visit occurred that 

qualified the Veteran as beginning a new episode of care or where the Veteran was 

discharged from inpatient SUD care). 

o If the patient passed the first 30-day retention interval requirement but failed to meet 

the 2nd 30-day retention interval requirement, the patient fails the measure and the 

failure is attributed to the facility where the latest retention visit occurred. 

Exclusions:

 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A

VA Office of Inspector General 11

o If the patient passed the first and second 30-day retention interval requirement but 

failed to meet the 3rd 30-day retention interval requirement, the patient fails the 

measure and the failure is attributed to the facility where the latest retention visit 

occurred.

Data Origin: Workload generated in VistA and sent to AITC. Data submitted after the quarterly 

report has been collected pertaining to Veteran care already reported will be updated during the 

following quarterly run. 

Extraction: 100% from AITC database by OQP. 

This table answers the question: Will these sources be used to contribute information for specified 

period/event

TABLE A. Events / Data Source Use During Dormancy, Qualification, and Retention Determination 

Dormant Qualifying Retention

SUD Clinic 

stops (513, 

514, 519, 523, 

545, 547, 548 

and 560)

SUD clinic stops 513, 514, 

519, 523, 545, 547, 548 and 

560 are used to evaluate the 

dormant period. E.g. I f the 

patient has and of these SUD 

clinic stops, they will be 

considered “NOT dormant” 

and do not newly qualify for 

the measure for at least 90 

more days.

Only SUD clinic stops 513, 547, 548 

and 560 will be used to qualify a 

Veteran. F or example, if a Veteran 

has 3 visits in 30 days, he qualifies in 

the measure.

SUD clinic stops 513, 

514, 519, 523, 545 

[note exception during 

first 30 day retention 

period], 547, 548 and 

560 will be used to 

determine retention 

compliance.

SA/Home 514 Yes. SA/Home clinic stop 

514 will be used to evaluate 

the dormant period. For 

example, Pt is receiving SUD 

‘maintenance’ care in a Grant 

& Per Diem program (514) so 

will ‘show-up’ in a search for 

‘dormant time’ and ‘count’ as 

SUD visits, therefore the 

patient will not be ‘dormant’ 

if 514 visits are present.

No. 514 will NOT be used to 

evaluate for qualifying events. E.g. 

Pt has a true dormant period (no 

SUD workload in 90 days) then 3 

visits in 30 days with a 514 code. 

This workload will NOT be used to 

determine a ‘qualifying’ event. The 

patient will not be considered newly 

‘qualified’ based on 514 workload.

Yes. 514 clinic stops 

will be used to 

determine retention 

compliance in all 3 

retention periods

SA/PTSD 519 Yes. SA/PTSD clinic stop 

519 will be used to evaluate 

the dormant period. For 

example, Pt is receiving SUD 

‘maintenance’ care in a PTSD 

Outpatient clinic (519) so will 

‘show-up’ in a search for 

‘dormant time’ and ‘count’ as 

SUD visits, therefore the 

patient will not be ‘dormant’ 

if 519 visits are present.

No. 519 will NOT be used to 

evaluate for qualifying events. E.g. 

Pt has a true dormant period (no 

SUD workload in 90 days) then 3 

visits in 30 days with a 519 code. 

This workload will NOT be used to 

determine a ‘qualifying’ event. The 

patient will not be considered newly 

‘qualified’ based on 519 workload.

Yes. 519 clinic stops 

will be used to 

determine retention 

compliance in all 3 

retention periods

Methodology: 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A

VA Office of Inspector General 12

TABLE A. Events / Data Source Use During Dormancy, Qualification, and Retention Determination 

Dormant Qualifying Retention

Opioid 

Substitution 

523

Yes. Opioid Substitution 

clinic stop 523 will be used to 

evaluate the dormant period. 

For example, Pt is receiving 

SUD ‘maintenance’ care in a 

Opioid Substitution program 

(523) so will ‘show-up’ in a 

search for ‘dormant time’ and 

‘count’ as SUD visits, 

therefore the patient will not 

be ‘dormant’ if 523 visits are 

present.

No. 523 will NOT be used to 

evaluate for qualifying events. E.g. 

Pt has a true dormant period (no 

SUD workload in 90 days) then 3 

visits in 30 days with a 523 code. 

This workload will NOT be used to 

determine a ‘qualifying’ event. The 

patient will not be considered newly 

‘qualified’ based on 523 workload.

Yes. 523 clinic stops 

will be used to 

determine retention 

compliance in all 3 

retention periods

Telephone 

stop 545

Yes. Telephone clinic stop 

545 will be used to evaluate 

the dormant period. For 

example, Pt is receiving SUD 

‘maintenance’ telephone care 

(545) so will ‘show-up’ in a 

search for ‘dormant time’ and 

‘count’ as SUD visits, 

therefore the patient will not 

be ‘dormant’ if 545 visits are 

present.

No. 545 will NOT be used to 

evaluate for qualifying events. E.g. 

Pt has a true dormant period (no 

SUD workload in 90 days) then 3 

telephone visits in 30 days. This 

workload will NOT be used to 

determine a ‘qualifying’ event. The 

patient will not be considered newly 

‘qualified’ based on 545 workload.

Yes. 545 clinic stops 

will be used to 

determine retention 

compliance in the 2nd 

& 3rd period only

Inpatient SUD 

Dischg w/ 

LOS ≥ 4 

calendar days

Yes. Discharge data will be 

evaluated and considered as 

active SUD workload when 

evaluating the dormant period. 

Therefore, if a patient has an 

admission or discharge during 

the dormant period, it will not 

be considered ‘dormant’. 

Yes. Discharge data from an inpt 

SUD bed section will be used as a 

qualifying event. Such a discharge 

will ‘disconnect/drop’ a Veteran 

from any previous qualifying track 

AND will re-qualify a patient with a 

new qualifying date.

Yes. If a patient was 

ADMITTED to a SUD 

Bed Section during the 

retention period, those 

data will be used to 

‘disconnect’ him from

the previous qualifying 

track. He will be requalified upon 

discharge or transfer 

from the SUD Bed sec. 

Inpatient w/ 

SUD 

Encounters1

No. SUD encounters 

provided on inpatients will 

NOT be used to evaluate for a 

dormant period. Therefore if 

a patient has received SUD 

consult while an inpatient (on 

any bed section), it will not be 

considered when evaluating 

for a dormant period. If the 

patient had ONLY inpatient 

encounters for 90 days, he will 

be considered as having a 

‘dormant’ period.

No. SUD encounters provided on 

inpatients will NOT be used to 

evaluate for qualifying events

Yes. SUD encounters 

provided on inpatients 

will be used to evaluate 

retention compliance 

 

1

These are ‘encounter forms’ generated while a patient is admitted to an inpatient bed section. Prior to 2005, ‘outpatient’ 

workload for ‘inpatients’ was ‘blocked’ at the facility and not submitted to the Austin Automation Center. I n 2005, VHA 

removed this block and allows encounters for professional workload provided to inpatients to be sent to Austin. See Directive 

2006-026 at http://vaww1.va.gov/vhapublications/publications.cfm?pub=1 Attachment A
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A

VA Office of Inspector General 13

TABLE A. Events / Data Source Use During Dormancy, Qualification, and Retention Determination 

Dormant Qualifying Retention

Census on 

SUD bed 

section w/ 

LOS ≥ 4 

calendar days

No. SUD census data will not 

be used to evaluate a dormant 

period (when the patient is 

discharged, the measure will 

pick-up the discharge 

information)

No. SUD census data will not be 

used to evaluate for a qualifying 

event (when the patient is 

discharged, the measure will pick-up 

the discharge information)

Yes (partially). SUD 

census data will be 

used to evaluate 

whether to ‘disconnect’ 

a vet from previous 

qualifying track. But it 

will not be used to meet 

retention visit 

requirements. The 

patient will be requalified upon 

discharge from the 

SUD Bed Section. 

 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A

VA Office of Inspector General 14

Measurement period:

Reporting: Time frame issues: Reports include patients who have completed the retention 

period during the report month or quarter selected. The performance period is consistent with 

EPRP quarters. 

TABLE B. Substance Use Disorder Reporting Timelines and Workload Inclusion Information 

EPRP 

Lagged 

Quarter 

Months 

included in 

quarter = 

Patients 

completing 

their 

retention 

period in:

OQP 

Executive 

Briefing 

Book 

Reporting 

Date

Dormancy 

Check Range 

(T- days to 

first 

qualification 

visit date -90)

Index 

Episode 1st 

Qualification 

Visit Date 

Range for 

Outpatient 

Qualification

Index 

Episode 

Qualification 

Date (T) 

Range 

Index 

Episode 

Retention 

Start Date 

(T+1) 

Range

Index 

Episode 

Retention 

Completion 

Date (T+90) 

Range

1 

Oct , Nov First 

Friday 

February 

10

03/06/09 -

05/05/09

06/04/09 –

08/30/09

07/03/09-

09/01/09

07/04/09

09/02/09

10/01/09 -

11/30/09

2 

Oct, Nov, 

Dec, Jan, 

Feb 

First 

Friday 

May 10

03/06/09 -

08/31/09

06/04/09 –

11/29/09

07/03/09 -

12/01/09

07/04/09–

12/02/09

10/01/09-

02/28/10

3 

Oct, Nov, 

Dec, Jan, 

Feb, Mar, 

Apr, May 

First 

Friday 

August 

10 

03/06/09 –

12/01/09

06/04/09-

02/28/10

07/03/09-

03/02/10

07/04/09–

03/03/10

10/01/09 -

05/31/10

4 

Oct, Nov, 

Dec, Jan, 

Feb, Mar, 

Apr, May, 

Jun, Jul, 

Aug 

MidOctober 

10 

03/06/09 -

03/02/10

06/04/09 –

05/31/10

07/03/09-

06/02/10

07/04/09-

06/03/10

10/01/09-

08/31/10

Repository: Monthly, facility, VISN, VHA and SSN specific data are available for trouble 

shooting and understanding local patterns retrospectively after the completion of a retention 

period; however this is not sufficiently close to ‘real time’ data to provide prospective tracking 

during the retention period. See VSSC Web http://vssc.med.va.gov/PM/SUD.asp 

• There are 3 events in time analyzed in this measure:

o Negative SUD Treatment History also called Dormancy

o New SUD treatment episode through outpatient or inpatient qualification

o Continuous treatment involvement during the retention period of three 30 day intervals 

Definitions (decision rule specific): 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A

VA Office of Inspector General 15

TABLE C. Events in Time 

Event Negative SUD 

Treatment 

History 

(Dormancy)

Qualification as New SUD Episode Continuous Treatment Involvement 

(Retention Period) 90 Total Days

Event 

Description

90 day period 

of no SUD 

treatment in 

the 90 days 

prior to the 1st 

outpatient 

qualifying 

event date

Inpatient or Outpatient Qualification 

Date = T 

1st 30 days 

of retention

2nd 30 days 

of retention 

3rd 30 days 

of retention

Outpatient 

Qualified 

Events in 

Time 

(T-90) minus 

total days from 

1st to 3rd 

outpatient 

qualifying 

event 

1st 

Qualifying 

Event Date

Not earlier 

than T-29

2nd 

Qualifying 

Event Date

Not earlier 

than T-28

3rd 

Qualifying 

Event Date

T 

2 SUD visits 

in period 

greater than 

T but not 

later than 

T+30

2 SUD visits 

in period 

greater than 

T+30 but 

not later 

than T+60

2 SUD visits 

in period 

greater than 

T+60 but 

not later 

than T+90

Inpatient 

Qualified 

Events in 

Time

None required 

for inpatient 

qualification 

1st and only Qualifying event T = Date 

of any inpatient discharge or transfer 

from a SUD bed-section

2 SUD visits 

in period 

greater than 

T but not 

later than 

T+30

2 SUD visits 

in period 

greater than 

T+30 but 

not later 

than T+60

2 SUD visits 

in period 

greater than 

T+60 but 

not later 

than T+90

• Veterans beginning new SUD treatment episode: To qualify as a New SUD Outpatient

o A 90-day Negative SUD outpatient or inpatient treatment history (no SUD outpatient 

visit/encounter, [513,514,519,523,545,547,548,560], specialty SUD inpatient 

admission or discharge or inpatient SUD encounters) before the date of the 1st of three 

qualifying SUD outpatient visits and 

Episode, two criteria must be met: 

o Three visits within 30 days to outpatient SUD clinic stops 513 SA-IND or 547 interSA TRT GRP, or 548 intensive-SA TRT IND or 560 SA GRP. Listed stops are 

included if paired with other stops as primary or secondary except when paired with 

smoking cessation 707. SUD Telephone visits (Stop Code 545) or 514 SA HOME or 

519 SA/PTSD or 523 Opioid Substitution will NOT be used to qualify new SUD 

treatment episodes. 

o The date of the 3rd SUD visit in 30 days is the “qualifying” date for the outpatient 

track. The retention period begins the next day.
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A

VA Office of Inspector General 16

Patients who generate outpatient workload while in an inpatient SUD bed section will not 

“qualify” for the measure via the outpatient track. Since inpatient workload may not be available 

until after discharge, the patient may be “picked up” as new and tracked for a period of time. 

However, upon SUD specialty inpatient discharge or transfer, the outpatient track will be 

dropped and the patient will be qualified in the inpatient track. 

To qualify as a New SUD Inpatient

• Discharge or transfer from SUD inpatient bed section (PTF Discharge Specialty 27 SA Res 

Rehab or 74 SA HI INT, 86 DOM SA with a length of stay at least 4 calendar days). 

Episode, a single criterion must be met:

o Note: Effective January 1, 2010, SARRTP beds will be assigned the new treating 

specialty code of #1M. The current SARRTP Treating Specialty Code # 27 will be 

discontinued at that time. Each SARRTP will be assigned a Domiciliary Suffix as 

outlined in Treating Specialty Codes Memorandum, MH RRTP Treating Specialty 

Code and Suffix Guidance and Suffix and Treating Specialty Code Assignments in the 

Technical Manual Vol. 3: References and Resources. 

The SUD bed section discharge or transfer date is the “qualifying” date for the inpatient track. 

The retention period begins the next day. 

• Continuous Treatment Involvement (Retention period): Continuous treatment 

involvement for at least 90 days is defined as visits on at least 2 days during every 30 day 

retention interval for a total of 90 days (three discrete 30 day intervals) in any of the 

outpatient specialty SUD clinics. The continuous SUD treatment retention period begins 

the day after the qualifying date and ends the 90th day from the beginning of the 

continuous treatment involvement retention period. 

• Telephone care: Substance use disorder clinical care by telephone which meets the same 

standard as face-to-face visits (e.g. staff qualifications, time spent with the Veteran, etc.) 

will be accepted for continuity of care for visits during the 2nd and 3rd 30-day retention 

intervals. Stop code 545 (Telephone/Substance Abuse) will be used for the measure. 

Telephone visits will not be used to “qualify” new Veterans into the measure. 

• Admission during the retention period: If a Veteran has already qualified for the 

measure (from the inpatient or the outpatient tracks) and, during the retention period has an 

admission to or a discharge from one of the SUD inpatient bed sections listed above: 

o LOS < 4 calendar days will have no effect on the measure.
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment A

VA Office of Inspector General 17

o LOS of at least 4 calendar days, the Veteran will be dropped from the previous 

qualifying track. Upon discharge or transfer from the SUD bed section, he will requalify for the measure.

 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment B

VA Office of Inspector General 18

Department of

Veterans Affairs Memorandum

Date: January 7, 2011

From: Chief Research and Development Officer

Subj: Management Representation Letter for the Independent Review of the VA’s FY 2010 Performance 

Summary Report to the Office of National Drug Control Policy (Project Number 2011-00314-R1-0011)

To: Assistant Inspector General for Audits and Evaluations (52)

We are providing this letter in connection with your attestation review of our Performance Summary 

Report to the Director, Office of National Drug Control Policy (ONDCP).

We confirm, to the best of our knowledge and belief, that the following representations made to you 

during your attestation review are accurate and pertain to the fiscal year ended September 30, 2010.

1. We confirm that we are responsible for and have made available to you the following:

a. The Performance Summary Report for FY 2010 required by the Circular;

b. All supporting records and related information and data relevant to the FY 2010 Performance 

Summary Report; and

c. Communications, if any, from the ONDCP and other oversight bodies concerning the FY 2010 

Performance Summary Report and information therein.

2 We confirm that the FY 2010 Performance Summary Report was prepared in accordance with the 

requirements and criteria of the Circular.

3. We understand your review was conducted in accordance with the attestation standards established 

by the American Institute of Certified Public Accountants, and the applicable standards contained in 

Government Auditing Standards, issued by the Comptroller General of the United States. An 

attestation review is substantially less in scope than an examination and accordingly, you will not 

express an opinion on the Performance Summary Report and related disclosures.

4. No events have occurred subsequent to September 30, 2010, that would have an effect on the 

Performance Summary Report and the information therein.

(original signed by:) 

Joel Kupersmith, MD

Attachment
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment B

VA Office of Inspector General 19

Office of Research and Development,

Department of Veterans Affairs

Fiscal Year 2010 Performance Summary Report

To the Office of National Drug Control Policy

1. Performance Information

Performance Measure: Each fiscal year the Office of Research and Development (ORD) will 

have at least 10 ongoing studies directly related to substance abuse disorder: 5 ongoing studies 

related to alcohol abuse and 5 ongoing studies related to other substance abuse. 

How the measure is used in the program: Most ORD-funded studies are investigator-initiated. 

Many clinicians who treat patients also perform research, so their research is targeted at diseases 

and disorders that they treat. Investigators will be encouraged to undertake research in this 

important area.

Performance results for the previous fiscal years: In fiscal year (FY) 2008, ORD funded 17 

studies related to substance abuse disorder, 38 related to alcohol abuse, and 14 that were related 

to both substance abuse disorder and alcohol abuse. In FY 2009, ORD funded 20 studies related 

to substance abuse disorder, 45 related to alcohol abuse, and 10 related to both. 

Comparison of the most recent fiscal year to its target: The targets for FY 2010 were 

exceeded. See Table 1.

Target for the current fiscal year: Although the actual values (number of studies) exceeded the 

target for FY 2010, we have not increased the target for FY 2011. This is because there is wide 

variation in the amount of funding per project. The more expensive studies are usually multisite 

clinical trials. Leaving the target at its present level would allow flexibility in the types of 

studies that are funded. 

Procedures used to ensure that the performance data is accurate, complete, and unbiased. 

The data is obtained from the Office of Research and Development’s (ORD’s) database that lists 

all of its funded projects. A report is produced that lists all funds sent to the VA medical centers 

for projects on drug and alcohol dependence for the four ORD services for a given fiscal year. 

The number of projects in the list is counted. 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment B

VA Office of Inspector General 20

Table 1

Measure

FY

2008 

Actual

FY 

2009 

Actual

FY 

2010 

Target

FY 

2010 

Actual

FY 

2011 

Target

Number of ongoing research 

studies related to substance 

abuse disorder 

17 20 5 21 5 

Number of ongoing research 

studies related to alcohol abuse 38 45 5 46 5 

Number of ongoing research 

studies related to both substance 

abuse disorder and alcohol abuse 

14 10 14 

2. Management Assertions 

Performance reporting system is appropriate and applied.

The VA Office of Research and Development (ORD) consists of four main divisions: 

Biomedical Laboratory: Supports preclinical research to understand life processes from the 

molecular, genomic, and physiological level in regard to diseases affecting Veterans. 

Clinical Science: Administers investigations, including human subject research, to determine 

feasibility or effectiveness of new treatments (e.g., drugs, therapy, or devices) in small 

clinical trials or multi-center cooperative studies, aimed at learning more about the causes of 

disease and developing more effective clinical care. 

The Cooperative Studies Program (CSP) is a major division within Clinical Science R&D 

that specializes in designing, conducting, and managing national and international multi-site 

clinical trials and epidemiological research. 

Health Services: Supports studies to identify and promote effective and efficient strategies 

to improve the organization, cost-effectiveness, and delivery of quality healthcare to 

Veterans.

Rehabilitation: Develops novel approaches to restore Veterans with traumatic amputation, 

central nervous system injuries, loss of sight and/or hearing, or other physical and cognitive 

impairments to full and productive lives. 

In order for funds to be allocated to a project, they must be entered into the Research 

Analysis Forecasting Tool (RAFT) database. 

Starting in FY 2009, all Merit Review proposals (our major funding mechanism) were submitted 

electronically via the eRA Commons system, and projects that were approved for funding were 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment B

VA Office of Inspector General 21

identified. Funding data for these projects were transferred electronically to RAFT. A few 

Career Development proposals are included in the list of projects. The capability to submit 

Career Development proposals electronically via eRA Commons was in place near the end of FY 

2010, but none of the projects that were funded in FY 2010 were submitted using that 

mechanism. For FY 2010 these proposals were tracked via spreadsheets and uploaded into 

RAFT manually (HSR&D and RR&D) or electronically (BLR&D and CSR&D).

Preparation of the list of projects:

The BLR&D/CSR&D administrative officer extracted all funded projects for the fiscal year from 

RAFT and exported the data into an Excel spreadsheet. The alcohol and drug abuse projects 

were identified by reviewing the title. Any questionable projects were verified as relevant or not 

relevant upon review of the abstract. In some cases, the title listed was the type of investigator 

award. For those, the title was obtained from the abstract. Project start and end dates were 

included in the spreadsheet. If there were multiple researchers or a researcher with multiple 

funds for the same project (e.g., salary award plus Merit Review award), then the earliest start 

date and latest end date were used. Although great care is taken to provide an inclusive list of 

projects, our database management system does not have robust reporting capabilities, so some 

projects may have been omitted. 

For FY 2010, no RR&D projects related to drug or alcohol abuse were identified. 

Explanations for not meeting performance targets are reasonable.

Not applicable. The targets were met.

Methodology to establish performance targets is reasonable and applied. 

VA Research and Development focuses on research on the special healthcare needs of Veterans 

and strives to balance the discovery of new knowledge and the application of these discoveries to 

Veterans’ healthcare. VA Research and Development’s mission is to “discover knowledge and 

create innovations that advance the health and care of Veterans and the Nation.” ORD supports 

preclinical, clinical, health services, and rehabilitation research. This research ranges from 

studies relevant to our aging Veterans (e.g., cancer, heart disease, Alzheimer’s disease) to those 

relevant to younger Veterans returning from the current conflicts (e.g., PTSD, spinal cord 

injury). The targets were set at that level to allow flexibility in the projects funded in terms of 

both subject (e.g., cancer, addiction, heart disease) and type (e.g., preclinical, clinical trials). 

Adequate performance measures exist for all significant drug control activities. 

Since many of the projects do not involve direct interaction with patients, the measure looks at 

the number of projects rather than specific activities. 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment C 

VA Office of Inspector General 22

ONDCP Circular: Drug Control Accounting 

May 1, 2007

TO THE HEADS OF EXECUTIVE DEPARTMENTS AND ESTABLISHMENTS 

SUBJECT: Annual Accounting and Authentication of Drug Control Funds and Related Performance 

1. Purpose. This circular provides the policies and procedures to be used by National Drug 

Control Program agencies in conducting a detailed accounting and authentication of all funds 

expended on National Drug Control Program activities and the performance measures, targets, and 

results associated with those activities. 

2. Rescission. This circular rescinds and replaces the ONDCP Circular, Annual Accounting of 

Drug Control Funds, dated April 18, 2003. 

3. Authority. 

a. 21 U.S.C. § 1704(d) provides: “The Director [ONDCP] shall – 

(A) require the National Drug Control Program agencies to submit to the Director not later 

than February 1 of each year a detailed accounting of all funds expended by the agencies for 

National Drug Control Program activities during the previous fiscal year, and require such 

accounting to be authenticated by the Inspector General of each agency prior to submission to 

the Director; and 

(B) submit to Congress not later than April 1 of each year the information submitted to the 

Director under subparagraph (A).” 

b. 21 U.S.C. § 1703(d)(7) a uthorizes the Director of National Drug Control Policy to “... monitor 

implementation of the National Drug Control Program, including – (A) conducting program and 

performance audits and evaluations; and (B) re questing assistance of the Inspector General of the 

relevant agency in such audits and evaluations ...” 

4. Definitions. As used in this circular, key terms related to the National Drug Control Program 

and budget are defined in Section 4 of the ONDCP Circular, Budget Formulation, dated 

May 1, 2007. These terms include: National Drug Control Program, National Drug Control 

Program agency, Bureau, Drug Methodology, Drug Control Functions, and Budget Decision Units. 

Further, Reprogrammings and Fund Control Notices referenced in Section 6 of this circular are 

defined in Section 6 and Section 8 of the ONDCP Circular, Budget Execution, dated May 1, 2007. 

5. Coverage. The provisions of this circular apply to all National Drug Control Program 

agencies. 

6. Detailed Accounting Submission. The Chief Financial Officer (CFO) of each agency, or 

other accountable senior level senior executive, shall prepare a Detailed Accounting Submission to 

the Director, ONDCP. For agencies with no bure aus, this submission shall be a single report, as 

defined by this section. For agencies with bureaus, the Detailed Accounting Submission shall consist 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment C 

VA Office of Inspector General 23

of reports, as defined by this section, from the agency’s bureaus. The CFO of each bureau, or 

accountable senior level executive, shall prepare reports. Each report must include (a) a table 

highlighting prior year drug control obligations data, and (b) a narrative section making assertions 

regarding the prior year obligations data. Report elements are further detailed below: 

a. Table of Prior Year Drug Control Obligations – For the most recently completed fiscal 

year, each report shall include a table of obligations of drug control budgetary resources 

appropriated and available during the year being reported.2

 

Such table shall present 

obligations by Drug Control Function and Budget Decision Unit, as these categories are 

displayed for the agency or bure au in the National Drug Control Strategy Budget 

Summary. Further, this table shall be accompanied by the following disclosures: 

(1) Drug Methodology – The drug methodology shall be specified in a separate exhibit. 

For obligations calculated pursuant to a drug methodology, this presentation shall 

include sufficient detail to explain fully the derivation of all obligations data presented 

in the table. 

(a) Obligations by Drug Control Function – All bureaus employ a drug 

methodology to report obligations by Drug Control Function. 

(b) Obligations by Budget Decision Unit – For certain multi-mission bureaus – 

Customs and Border Protection (CBP), Coast Guard, Immigration and Customs 

Enforcement (ICE), Indian Health Service (IHS), Bureau of Indian Affairs (BIA), 

and the Veterans Health Administration (VHA) – obligations reported by Budget 

Decision Unit shall be calculated pursuant to an approved drug methodology. For 

all other bureaus, drug control obligations reported by Budget Decision Unit shall 

represent 100 percent of the actual obligations of the bureau for those Budget

Decision Units, as they are defined for the National Drug Control Budget. (See 

Attachment B of the ONDCP Circular, Budget Formulation, dated May 1, 2007.) 

(2) Methodology Modifications – Consistent with ONDCP’s prior approval, if the drug 

methodology has been modified from the previous year, then the changes, their 

purpose, and the quantitative differences in the amount(s) reported using the new 

method versus the amount(s) that would have been reported under the old method 

shall be disclosed.3

(3) Material Weaknesses or Other Findings – Any material weakness or other findings 

by independent sources, or other known weaknesses, including those identified in the 

 

2 Consistent with reporting requirements of the ONDCP Circular, Budget Formulation, dated May 1, 2007, 

resources received from the following accounts are excluded from obligation estimates: (1) ONDCP – High 

Intensity Drug Trafficking Areas (HIDTA) and (2) DOJ – Organized Crime Drug Enforcement Task Force Program. 

Obligations against these resources shall be excluded from table required by this section but shall be reported on a 

consolidated basis by these bureaus. Generally, to prevent double-counting agencies should not report obligations 

against budget resources received as a reimbursement. An agency that is the source of the budget authority for such 

reimbursements shall be the reporting entity under this circular. 

3 For changes that did not receive prior approval, the agency or bureau shall submit such changes to ONDCP for 

approval under separate cover.
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment C 

VA Office of Inspector General 24

Agency’s Annual Statement of Assurance, which may affect the presentation of prior 

year drug-related obligations data, shall be highlighted. This may be accomplished by 

either providing a brief written summary, or by referencing and attaching relevant 

portions of existing assurance reports. For each material weakness or other finding, 

corrective actions currently underway or contemplated shall be identified. 

(4) Reprogrammings or Transfers – All prior year reprogrammings or transfers that 

affected drug-related budgetary resources shall be identified; for each such 

reprogramming or transfer, the effect on drug-related obligations reported in the table 

required by this section also shall be identified. 

(5) Other Disclosures – Agencies may make such other disclosures as they feel are 

necessary to clarify any issues regarding the data reported under this circular. 

b. Assertions – At a minimum, each report shall include a narrative section where the 

following assertions are made regarding the obligation data presented in the table required 

by Section 6a: 

(1) Obligations by Budget Decision Unit – With the exception of the multi-mission 

bureaus noted in Section 6a(1)(b), reports under this section shall include an assertion 

that obligations reported by budget decision unit are the actual obligations from the 

bureau’s accounting system of record for these Budget Decision Units. 

(2) Drug Methodology – An assertion shall be made regarding the reasonableness and 

accuracy of the drug methodology used to calculate obligations of prior year budgetary 

resources by function for all bureaus and by budget decision unit for the CBP, Coast 

Guard, ICE, IHS, BIA, and VHA. The criteria associated with this assertion are as 

follows: 

(a) Data – If workload or other statistical information supports the drug methodology, 

then the source of these data and the current connection to drug control obligations 

should be well documented. If these data are periodically collected, then the data 

used in the drug methodology must be clearly identified and will be the most 

recently available. 

(b) Other Estimation Methods – If professional judgment or other estimation 

methods are used as part of the drug methodology, then the association between 

these assumptions and the drug control obligations being estimated must be 

thoroughly explained and documented. These assumptions should be subjected to 

periodic review, in order to confirm their continued validity. 

(c) Financial Systems – Financial systems supporting the drug methodology should 

yield data that fairly present, in all material respects, aggregate obligations from 

which drug-related obligation estimates are derived. 

(3) Application of Drug Methodology – Each report shall include an assertion that the 

drug methodology disclosed in this section was the actual methodology used to 

generate the table required by Section 6a. Calculations must be sufficiently well 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment C 

VA Office of Inspector General 25

documented to independently reproduce these data. Calculations should also provide a 

means to ensure consistency of data between reporting years. 

(4) Reprogrammings or Transfers – Further, each report shall include an assertion that 

the data presented are associated with obligations against a f inancial plan that, if 

revised during the fiscal year, properly reflects those changes, including ONDCP’s 

approval of reprogrammings or transfers affecting drug-related resources in excess of 

$1 million. 

(5) Fund Control Notices – Each report shall also include an assertion that the data 

presented are associated with obligations against a financial plan that fully complied 

with all Fund Control Notices issued by the Director under 21 U.S.C. § 1703(f) and 

Section 8 of the ONDCP Circular, Budget Execution. 

7. Performance Summary Report. The CFO, or ot her accountable senior level senior 

executive, of each agency for which a Detailed Accounting Submission is required, shall provide a 

Performance Summary Report to the Director of National Drug Control Policy. Each report must 

include performance-related information for National Drug Control Program activities, and the 

official is required to make certain assertions regarding that information. The required elements of 

the report are detailed below. 

a. Performance Reporting– The agency’s Performance Summary Report must include each of 

the following components: 

(1) Performance Measures – The report must describe the performance measures used 

by the agency to assess the National Drug Control Program activities it carried out in 

the most recently completed fiscal year and provide a clear justification for why those 

measures are appropriate for the associated National Drug Control Program activities. 

The performance report must explain how the measures: reflect the purpose of the 

program; contribute to the National Drug Control Strategy; and are used in the 

management of the program. The description must include sufficient detail to permit 

non-experts to understand what is being measured and why it is relevant to those 

activities. 

(2) Prior Years Performance Targets and Results – For each performance measure, the 

report must provide actual performance information for the previous four fiscal years 

and compare the results of the most recent fiscal year with the projected (target) levels 

of performance established in the agency’s annual performance budget for that year. 

If any performance target for the most recently completed fiscal year was not met, the 

report must explain why that target was not met and describe the agency’s plans and 

schedules for meeting future targets. Alternatively, if the agency has concluded it is 

not possible to achieve the established target with available resources, the report 

should include recommendations concerning revising or eliminating the target. 

(3) Current Year Performance Targets – Each report must specify the performance 

targets established for National Drug Control Program activities in the agency’s 

performance budget for the current fiscal year and describe the methodology used to 

establish those targets. 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment C 

VA Office of Inspector General 26

(4) Quality of Performance Data – The agency must state the procedures used to ensure 

the performance data described in this report are accurate, complete, and unbiased in 

presentation and substance. 

b. Assertions – Each report shall include a letter in which an accountable agency official 

makes the following assertions are made regarding the information presented in Section 

7a: 

(1) Performance reporting system is appropriate and applied – The agency has a 

system to capture performance information accurately and that system was properly 

applied to generate the performance data. 

(2) Explanations for not meeting performance targets are reasonable – An assertion 

shall be made regarding the reasonableness of any explanation offered for failing to 

meet a performance target and for any recommendations concerning plans and 

schedules for meeting future targets or f or revising or e liminating performance 

targets. 

(3) Methodology to establish performance targets is reasonable and applied – An 

assertion that the methodology described above to establish performance targets for 

the current year is reasonable given past performance and available resources. 

(4) Adequate performance measures exist for all significant drug control activities -

Each Report shall include an assertion that the agency has established at least one 

acceptable performance measure for each Drug Control Decision Unit identified in 

reports required by section 6a(1)(A) for which a significant amount of obligations 

($1,000,000 or 50 pe rcent of the agency drug budget, whichever is less) were 

incurred in the previous fiscal year. Each performance measure must consider the 

intended purpose of the National Drug Control Program activity. The criteria 

associated with these assertions are as follows: 

(a) Data – If workload, participant, or other quantitative information supports these 

assertions, the sources of these data should be well documented. If these data are 

periodically collected, the data used in the report must be clearly identified and will 

be the most recently available. 

(b) Other Estimation Methods – If professional judgment or ot her estimation 

methods are used to make these assertions, the objectivity and strength of these 

estimation methods must be thoroughly explained and documented. These estimation 

methods should be subjected to periodic review to confirm their continued validity. 

(c) Reporting Systems – Reporting systems supporting the assertions should be 

current, reliable, and an integral part of the agency’s budget and management 

processes. 

8. Inspector General Authentication. Each report defined in Sections 6 and 7 s hall be 

provided to the agency’s Inspector General (IG) for the purpose of expressing a conclusion about the 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment C 

VA Office of Inspector General 27

reliability of each assertion made in the report. ONDCP anticipates that this engagement will be an 

attestation review, consistent with the Statements for Standards of Attestation Engagements, 

promulgated by the American Institute of Certified Public Accountants. 

9. Unreasonable Burden. Unless a detailed report, as specified in Section 6, is specifically 

requested by ONDCP, an agency or bureau included in the National Drug Control Budget with prior 

year drug-related obligations of less than $50 million may submit through its CFO, or its accountable 

senior level executive, an alternative report to ONDCP, consisting of only the table highlighted in 

Section 6a., omitting all other disclosures. Such a report will be accompanied by statements from the 

CFO, or accountable senior level executive, and the agency IG attesting that full compliance with this 

Circular would constitute an unreasonable reporting burden. In those instances, obligations reported 

under this section will be considered as constituting the statutorily required detailed accounting, 

unless ONDCP notifies the agency that greater detail is required. 

10. Point of Contact and Due Dates. Each agency CFO, or accountable senior level executive, 

shall transmit a Detailed Accounting Submission, consisting of the report(s) defined in Sections 6 

and 7, along with the IG’s authentication(s) defined in Section 8, to the attention of the Associate 

Director for Performance and Budget, Office of National Drug Control Policy, Washington, DC 

20503. Detailed Accounting Submissions, with the accompanying IG authentication(s), are due to 

ONDCP by February 1 o f each year. Agency management must submit reports to their Office of 

Inspector General (OIG) in sufficient time to allow for review and IG authentication under Section 8 

of this Circular. ONDCP recommends a 31 D ecember due date for agencies to provide their 

respective OIG with the required reports and information. 
Independent Review of VA’s Fiscal Year 2010 Performance Summary Report to ONDCP

Attachment D 

VA Office of Inspector General 28

Report Distribution

VA Distribution 

Office of the Secretary

Veterans Health Administration

Office of General Counsel

Chief Patient Care Services Officer, Veterans Health Administration

Chief Quality and Performance Officer, Veteran Health Administration

Chief Research and Development Officer, Veterans Health Administration

Chief Financial Officer, Veterans Health Administration

Deputy Chief, Patient Care Services Officer for Mental Health, Veterans 

Health Administration

Director, Management Review Service, Veterans Health Administration

Director of Performance Management, Veterans Health Administration

Non-VA Distribution

House Committee on Veterans’ Affairs

House Appropriations Subcommittee on M ilitary Construction, Veterans 

Affairs, and Related Agencies

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs

Senate Appropriations Subcommittee on M ilitary Construction, Veterans 

Affairs, and Related Agencies

Senate Committee on Homeland Security and Governmental Affairs

Office of National Drug Control Policy