What’s up with the VA? Stephen Chensue, M.D. Ph.D. Chief, Pathology and Laboratory Medicine VA Ann Arbor Healthcare System

A Little Background The origin of the VA dates to the first federal military veterans hospital (Hand Hospital) in Pittsburgh in 1778 VA mission was formalized by Abraham Lincoln in pledge made to America's Civil War veterans during his Second Inaugural Address, in 1865 "To care for him who shall have borne the battle and for his widow and his orphan.“ 1930 established as Veterans Administration Distinct from the Department of Defense system of hospitals i.e. Walter Reed Hospital etc.

Department of Veteran Affairs Cabinet level department since 1989 Currently under Secretary Eric Shinseki 2009 Budget $87 billion

Department of Veteran Affairs Administrative Divisions Benefits education, disability etc. Healthcare physical and mental VBA VHA Cemetery burial services NCA

Veterans Health Administration Largest integrated healthcare system in nation 171 hub hospitals (many University affiliated) 350 community-based outpatient clinics (CBOCs) Due to its politically sensitive nature it is subject to intense scrutiny and oversight Healthcare quality and efficacy is based on defined patient outcome metrics A RAND Corporation study in 2004 concluded that the VHA outperforms all other sectors of American health care in 294 measures of quality

VHA Electronic Record System VHA was first to spearhead nationally integrated digital patient records known as CPRS ”computerized patient record system” Currently a VA patient can be seen at one or multiple VA hospitals in the nation and their complete records are available through web

Veterans Integrated Service Networks (VISNs)

VISN 11 8 Medical Center Hubs 1.Aleda E. Lutz VA Medical Center (Saginaw, MI) 2.Battle Creek VA Medical Center (Battle Creek, MI) 3.John D. Dingell VA Medical Center (Detroit, MI) 4.VA Ann Arbor Healthcare System (Ann Arbor, MI) 5.Richard L. Roudebush VA Medical Center (Indianapolis, IN) 6.VA Illiana Health Care System (Danville, IL) 7.VA Northern Indiana Health Care System - Marion Campus (Marion, IN) 8.VA Northern Indiana Health Care System-Fort Wayne Campus (Fort Wayne, IN) + 22 Community Outpatient Clinics North Tier South Tier

VA Ann Arbor Healthcare System Clinical Addition Opened 1999

VA Ann Arbor Healthcare System VA Ann Arbor Toledo CBOC Flint CBOC Jackson CBOC Main Laboratory 4 pathologists 45 technical 12 phlebotomists Toledo Laboratory 3.5 technical 1 phlebotomist POC testing 390K outpt 5.2K inpt 64K outpt 9K outpt8K outpt

VA Ann Arbor Healthcare Pathology and Laboratory Medicine Service (PALMS) CAP accredited laboratory responsible for laboratory and point-of- care testing activities at the Ann Arbor campus as well as Toledo, Flint and Jackson outpatient clinics. Provides all anatomic pathology services for both Ann Arbor and Battle Creek hubs. Provides Veteran Women’s Health services: PAP and GYN pathology for entire VISN 11 northern tier

Laboratory Activity 2,372,295 clinical pathology tests Ann Arbor site FY09 204,374 clinical pathology tests Toledo site FY09 Clinical Pathology

Anatomic Pathology

Anatomic Pathology Workload

No Net Increase in Employees

Ergonomic Grossing Station Programmable Rapid Processors Automated Stainer-Coverslipper State-of-Art Cryostats

VA Physician Pay Bill 2004 Implementation 2006 VA Physician Pay-Three Components 1.Base Pay: set amount based on years of service 2.Market Pay: supplement to match local market pay rate 3.Performance Pay: optional bonus component based on achieving designated performance goals and outcomes

VAAAHS Pathologist Performance Criteria 1.Completion of 7000 RVU annually (MGMA) 2.Surgical Report turn-around-time>95% within 48 hrs 3.Non-Gyn Cytology Report turn-around-time>95% within 48 hrs 4.Autopsy Report turn-around-time100% within 30 days 5.Frozen Section turn-around-time>95% within 20 min or less 6.Cancer template usage (report quality)100% of cancer resections 7.Documented consultation100% of external consults 8.Peer review major discrepancy<0.1% discrepant 9.Random peer review complete concordance>90% agreement 10.Frozen section concordance>95% of cases 11.External review and QA testing ratingfully satisfactory 12.Lab or hospital improvement initiativeone project/yr

Future VA Laboratory Challenges Continuing volume increases with aging of Vietnam era and disabled OIF/OEF veterans Aging medical technologist staff Compliance with mounting regulatory and documentation demands Demand to provide high cost diagnostic services vis-à-vis impending budgetary cuts

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