field personnel (notably a number of VA clinicians) began building a loosely linked network of computer capabilities at individual medical facilities. This network has come to be named the Decentralized Hospital Computer Program (DHCP). It provides a considerable source of medical facility operational and patient care information. The head of the DHCP reports to the CMD and the information system retains a field orientation. The CMD's office also contains the Boston Development Center, which is substantially involved in resource distribution analysis and related information. In addition to DHCP and the Boston center, which are within the medical system, the department--under the direction of the Assistant Secretary for Finance and Information Resources Management--runs a data processing center at Austin, Texas, containing a patient treatment file, outpatient and fee basis files and personnel and payroll data. Unlike the DHCP, this center relies on a mainframe computer system. There are assorted other information gathering and processing operations within the department. Not all information in DHCP is transferred to the Austin center, which maintains system-wide workload and financial data. Summary of Observations and Most of the information and reports suggests overlaps, gaps and a general "fuzziness" in the lines of authority responsibility at all levels of the health-care system and concludes that some fundamental changes are necessary in the way the system is managed if VA is to maintain high-quality health services delivery. The Northwestern study highlights some plans in process in the health-care system. In an attempt to set the stage for consideration of options for change, some general observations can be made about the organizational structure and managerial functioning of the system based on the Northwestern study, field personnel and presentations. First, the Department of Veterans Affairs is a complex and large organization with many missions. The health-care missions (patient care, health professional education, research and Department of Defense contingency) are certainly complicated, but the organizational context of the department extends beyond health care. There exist longstanding and strong relationships between all levels and all divisions of the department with members and committees in the Congress and with various veterans service organizations. These relationships are brought to bear from time to time in solving internal managerial and functional problems. Second, there have been recent, major changes in the organization and structure within VA and between VA and other governmental entities. These changes have occurred in a very short period of time. New positions have been created and functional relationships have shifted at the highest organizational levels and at the middle levels. The status of the system seems to have become unclear in the conversion to cabinet status and problematic in responding to Secretarial policy. What, for example, is the level of authority and responsibility of the CMD compared to the Assistant Secretaries? What is the relationship in policy formulation and execution among the various entities assigned the task of assuring quality of health care? Third, both policy formulation and operational responsibilities in VA health care seem to be lodged at high levels in the system, encumbered, as noted above, by a dramatic number of regulations, rules and other controls. There is little flexibility in the system for modifications to meet local needs. For example, the role of regional directors in policy and operations has become unclear. Further, while the triad of director/associate director/chief of staff is reported in the Northwestern study to be working well, the role of the chief of nursing is very tightly regulated. The formulation of policy for, and operation of, the construction program also are lodged at high levels in the system. There appears to be overlap of system responsibilities with those firms hired to design and construct/modify facilities. There is little flexibility for local management of construction operations. Fourth, while required by statutes, the multiple offices responsible for quality confuse local medical facilities and the Northwestern study suggests that their inspection/punishment activities are at times inconsistent with principles of Total Quality Management/Continuing Quality Improvement. Fifth, the organizational culture of the health-care system is built on mutual respect of its members but the number and complexity of regulations appear to mitigate against change to improve functioning. The maze of regulations and management from above are reported to undermine accountability. Perhaps as a result, incentives and awards are perceived not to be based on merit, and innovation/risk taking is discouraged. Sixth, information, its gathering and analysis are widely diffused throughout the department and within the health-care system. The nature of information for modern health-care management is not always available to policy and operations personnel. Report prepared by the Commission staff Structure, Function and Organization Committee Quinn H. Becker, M.D. Eugene Brickhouse, Col, USA John D. Church, Jr. Kathy Daane, MSN Barbara L. Gallagher Michael Herbert Gabriel Manasse, M.D. Mark S. Russell Committee chairman: Victor P. Raymond, Ph.D. Northwestern University Study Principal Investigator, Edward F.X. Hughes, M.D., Ph.D. Midwest HSR&D Field Program Director John G. Demakis, M.D. |